Provider Demographics
NPI:1255796991
Name:CMWL2
Entity type:Organization
Organization Name:CMWL2
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:COUSSONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-338-6868
Mailing Address - Street 1:2641 DEVELOPMENT DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4240
Mailing Address - Country:US
Mailing Address - Phone:920-338-6868
Mailing Address - Fax:
Practice Address - Street 1:1688 N CASALOMA DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8245
Practice Address - Country:US
Practice Address - Phone:920-707-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43795207VB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VB0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObesity MedicineGroup - Single Specialty