Healthcare Provider Details

I. General information

NPI: 1215169073
Provider Name (Legal Business Name): MILWAUKEE CLINIC OF ORTHO SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19035 W CAPITOL DR SUITE 101
BROOKFIELD WI
53045-2755
US

IV. Provider business mailing address

5233 W MORGAN AVE SUITE 102
MILWAUKEE WI
53220-1541
US

V. Phone/Fax

Practice location:
  • Phone: 414-321-8960
  • Fax: 414-321-0632
Mailing address:
  • Phone: 414-321-8960
  • Fax: 414-321-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: MS. MARY J BANACH
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-321-8960