Basic Information
| Provider Information | |||||||||
| NPI: | 1043503030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROHEALTH MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | N17W24100 RIVERWOOD DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629284100 | ||||||||
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| Practice Location | |||||||||
| Address1: | N57W24950 N CORPORATE CIR | ||||||||
| Address2: | |||||||||
| City: | SUSSEX | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530894383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628203093 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2011 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | GEISS, MD | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2629288669 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROHEALTH MEDICAL GROUP INC | ||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207ZH0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32652600 | 05 | WI | MEDICAID | 0505180002 | 01 | WI | DME | OTHER |