Provider Demographics
NPI:1932395209
Name:CLINIC OF COSMETIC SURGERY SC
Entity Type:Organization
Organization Name:CLINIC OF COSMETIC SURGERY SC
Other - Org Name:ROGER C MIXTER MD SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:SCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-963-0500
Mailing Address - Street 1:5201 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4902
Mailing Address - Country:US
Mailing Address - Phone:414-963-0500
Mailing Address - Fax:414-963-0359
Practice Address - Street 1:5201 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4902
Practice Address - Country:US
Practice Address - Phone:414-963-0500
Practice Address - Fax:414-963-0359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30618600Medicaid
WI30618600Medicaid
WI000002705Medicare PIN