MEDICARE: PROHEALTH MEDICAL GROUP INC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1750033841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROHEALTH MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	N17W24100 RIVERWOOD DR STE 250
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53188-1177
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 SPRING CITY DR
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53186-5934
Country	:	US
Telephone Number	:	262-928-0370
Fax Number	:

Authorized Official
Title or Position	:	REIMBURSEMENT MANAGER
Name	:	THOMAS W JOHNSON
Credential	:
Telephone Number	:	262-928-4704

Provider Enumeration Date	:	01/20/2022
Last Update Date	:	05/24/2022

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