Basic Information
Provider Information | |||||||||
NPI: | 1225318090 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CTVSA WISCONSIN S.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4400 W 95TH ST | ||||||||
Address2: | SUITE 205 | ||||||||
City: | OAK LAWN | ||||||||
State: | IL | ||||||||
PostalCode: | 604532654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7083464040 | ||||||||
FaxNumber: | 7083463287 | ||||||||
Practice Location | |||||||||
Address1: | 6308 8TH AVE | ||||||||
Address2: | SUITE 3060 | ||||||||
City: | KENOSHA | ||||||||
State: | WI | ||||||||
PostalCode: | 531435031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626562700 | ||||||||
FaxNumber: | 2626563672 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2011 | ||||||||
LastUpdateDate: | 08/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAPPAS | ||||||||
AuthorizedOfficialFirstName: | PATROKLOS | ||||||||
AuthorizedOfficialMiddleName: | STEVEN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7083464040 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X |   | WI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X |   | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
No ID Information.