Basic Information
| Provider Information | |||||||||
| NPI: | 1275598302 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAUWATOSA SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10900 W POTTER RD | ||||||||
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| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263424 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10900 W POTTER RD | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147749227 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLBUR | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4142084456 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.