Healthcare Provider Details

I. General information

NPI: 1801853387
Provider Name (Legal Business Name): ELMBROOK PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 W NORTH AVE SUITE 110E
BROOKFIELD WI
53005-4423
US

IV. Provider business mailing address

17000 W NORTH AVE SUITE 110E
BROOKFIELD WI
53005-4423
US

V. Phone/Fax

Practice location:
  • Phone: 262-786-8199
  • Fax: 262-786-0769
Mailing address:
  • Phone: 262-786-8199
  • Fax: 262-786-0769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: NANCY R. HAWORTH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 262-786-8199