Provider Demographics
NPI:1609881077
Name:ASCENSION MEDICAL GROUP-SOUTHEAST WISCONSIN INC
Entity type:Organization
Organization Name:ASCENSION MEDICAL GROUP-SOUTHEAST WISCONSIN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP-FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:J. BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3000
Mailing Address - Street 1:400 W RIVER WOODS PKWY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 W RIVER WOODS PKWY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-465-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000085375OtherMIDWEST CLINICAL LABS
WI32833500Medicaid
WI=========020OtherBCBS CLINIC #
WI=========079OtherBCBS CLINIC #
WI32833500Medicaid