Provider Demographics
NPI:1619611142
Name:SOUTHEAST WISCONSIN SURGERY CENTER LLC
Entity type:Organization
Organization Name:SOUTHEAST WISCONSIN SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHELSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LISLE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:402-631-8892
Mailing Address - Street 1:3801 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-2853
Mailing Address - Country:US
Mailing Address - Phone:402-631-8892
Mailing Address - Fax:
Practice Address - Street 1:3801 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-2853
Practice Address - Country:US
Practice Address - Phone:414-949-1938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-21
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043820442Medicaid
WI1447319496Medicaid