Provider Demographics
NPI:1386897965
Name:PROHEALTH MEDICAL GROUP INC
Entity type:Organization
Organization Name:PROHEALTH MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:T
Authorized Official - Last Name:GEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-928-8669
Mailing Address - Street 1:N17W24100 RIVERWOOD DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:262-928-4100
Mailing Address - Fax:262-928-5835
Practice Address - Street 1:820 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3900
Practice Address - Country:US
Practice Address - Phone:262-567-0223
Practice Address - Fax:262-567-6380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROHEALTH MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-28
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
68375Medicare PIN
WI0505180019Medicare NSC