Healthcare Provider Details

I. General information

NPI: 1871814293
Provider Name (Legal Business Name): PAULA BANSER OSTERHOUT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 08/30/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17345 CIVIC DR STE 1327
BROOKFIELD WI
53045-5070
US

IV. Provider business mailing address

17345 CIVIC DR STE 1327
BROOKFIELD WI
53045-5070
US

V. Phone/Fax

Practice location:
  • Phone: 414-447-7330
  • Fax: 414-447-1070
Mailing address:
  • Phone: 414-447-7330
  • Fax: 414-447-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number65051-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036.132101
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: