Provider Demographics
NPI:1528053295
Name:WISCONSIN CARDIOVASCULAR GROUP
Entity type:Organization
Organization Name:WISCONSIN CARDIOVASCULAR GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRAMBOW
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:414-271-1633
Mailing Address - Street 1:2315 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4518
Mailing Address - Country:US
Mailing Address - Phone:414-271-1633
Mailing Address - Fax:414-271-5071
Practice Address - Street 1:2315 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4518
Practice Address - Country:US
Practice Address - Phone:414-271-1633
Practice Address - Fax:414-271-5071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29385174400000X
WI28836174400000X
WI45947174400000X
WI21728174400000X
WI22535174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB53754Medicare UPIN
WIE90759Medicare UPIN
WIC65195Medicare UPIN
WIE13732Medicare UPIN
WIB56619Medicare UPIN