MEDICARE: PENINSULA PODIATRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies		WI
2	213E00000X	Podiatrist		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255425088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENINSULA PODIATRY LLC

Provider Business Mailing Address
First Line	:	BLDG 4 2
Second Line	:	30 NORTH 18TH AVENUE
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-3207
Country	:	US
Telephone Number	:	920-743-6668
Fax Number	:	920-743-9222

Provider Business Practice Location Address
First Line	:	BLDG 4 2
Second Line	:	30 NORTH 18TH AVENUE
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-3207
Country	:	US
Telephone Number	:	920-743-6668
Fax Number	:	920-743-9222

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	BRADLEY GERARD BURKART
Credential	:	DPM
Telephone Number	:	920-743-6668

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	02/05/2008

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Directions to “PENINSULA PODIATRY LLC ” Practice Location

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