Provider Demographics
NPI:1952304727
Name:SURGICAL SPECIALIST OF GREEN BAY INC.
Entity Type:Organization
Organization Name:SURGICAL SPECIALIST OF GREEN BAY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:V
Authorized Official - Last Name:GEONARIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-438-7155
Mailing Address - Street 1:720 S. VANBUREN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-438-7155
Mailing Address - Fax:920-438-7193
Practice Address - Street 1:720 S. VANBUREN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-438-7155
Practice Address - Fax:920-438-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32893700Medicare ID - Type Unspecified
WI000007705Medicare ID - Type Unspecified