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NPI Code Detail

MEDICARE: GARY MYRON M.D.

MEDICARE: GARY MYRON M.D.
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
1207Q00000XFamily Medicine Physician50315-020WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MYRONGAROTHERWIMERCYCARE INSURANCE
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
31664OTHERWIMERCYCARE INSURANCE
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
51386773174OTHERWIBCBSWI

General Provider Information

NPI Number : 1386773174
Entity Type Code : Individual
Provider Name (Legal Business Name) : GARY MYRON M.D.
Provider Business Mailing Address
First Line : 350 PELLER RD
Second Line :
City : LAKE GENEVA
State : WI
Zip : 53147-4543
Country : US
Telephone Number : 262-249-0221
Fax Number : 262-249-0633
Provider Business Practice Location Address
First Line : 350 PELLER RD
Second Line :
City : LAKE GENEVA
State : WI
Zip : 53147-4543
Country : US
Telephone Number : 262-249-0221
Fax Number : 262-249-0633
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/05/2007
Last Update Date : 05/08/2019

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