Healthcare Provider Details

I. General information

NPI: 1831343797
Provider Name (Legal Business Name): PEDIATRICS WEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 N BARKER RD SUITE 1
BROOKFIELD WI
53045-5230
US

IV. Provider business mailing address

1305 N BARKER RD SUITE 1
BROOKFIELD WI
53045-5230
US

V. Phone/Fax

Practice location:
  • Phone: 262-784-3200
  • Fax: 262-784-8198
Mailing address:
  • Phone: 262-784-3200
  • Fax: 262-784-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45644-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35609-020
License Number StateWI

VIII. Authorized Official

Name: LORELLE M MANION
Title or Position: MD
Credential: MD
Phone: 262-784-3200