Provider Demographics
NPI:1396774543
Name:WISCONSIN SURGERY CENTER LLC
Entity type:Organization
Organization Name:WISCONSIN SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VISHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-325-3737
Mailing Address - Street 1:PO BOX 210140
Mailing Address - Street 2:4131 W LOOMIS RD STE 300
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221
Mailing Address - Country:US
Mailing Address - Phone:414-325-3725
Mailing Address - Fax:414-325-3720
Practice Address - Street 1:3305 S 20TH ST
Practice Address - Street 2:STE 150
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-384-2100
Practice Address - Fax:414-384-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41913800Medicaid