Basic Information
| Provider Information | |||||||||
| NPI: | 1619908563 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAUSAU HEART & LUNG SURGEONS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 PINE RIDGE BLVD | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158470400 | ||||||||
| FaxNumber: | 7158470401 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 PINE RIDGE BLVD | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158470400 | ||||||||
| FaxNumber: | 7158470401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RIVERON | ||||||||
| AuthorizedOfficialFirstName: | FERNANDO | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7158470400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.