Basic Information
| Provider Information | |||||||||
| NPI: | 1841286291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR ASSOCIATES OF WISCONSIN, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 W KINNICKINNIC RIVER PKWY #840 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532143678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146493530 | ||||||||
| FaxNumber: | 4146493551 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 W KINNICKINNIC RIVER PKWY #840 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532143678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146493530 | ||||||||
| FaxNumber: | 4146493551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | KUSMIEREK | ||||||||
| AuthorizedOfficialFirstName: | WANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING LEAD | ||||||||
| AuthorizedOfficialTelephone: | 4142197845 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 32732600 | 05 | WI | MEDICAID |