Provider Demographics
NPI:1669111274
Name:KENOSHA SURGICENTER LLC
Entity type:Organization
Organization Name:KENOSHA SURGICENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:414-531-4327
Mailing Address - Street 1:2500 W LAYTON AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5400
Mailing Address - Country:US
Mailing Address - Phone:262-297-7246
Mailing Address - Fax:
Practice Address - Street 1:10105 74TH ST STE 102
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7530
Practice Address - Country:US
Practice Address - Phone:262-297-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-01
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical