Provider Demographics
NPI:1295780492
Name:WISCONSIN PHLEBOLOGY MEDICAL GROUP SC
Entity type:Organization
Organization Name:WISCONSIN PHLEBOLOGY MEDICAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMORUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-593-8460
Mailing Address - Street 1:PO BOX 1602
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-1602
Mailing Address - Country:US
Mailing Address - Phone:847-593-8460
Mailing Address - Fax:
Practice Address - Street 1:10614 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5013
Practice Address - Country:US
Practice Address - Phone:262-834-0123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2086S0129X, 202K00000X, 2085R0204X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty