Healthcare Provider Details

I. General information

NPI: 1205928553
Provider Name (Legal Business Name): ELMBROOK INTERNAL MEDICINE ASSOCIATES S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 W NORTH AVE SUITE 200E
BROOKFIELD WI
53005-4423
US

IV. Provider business mailing address

17000 W NORTH AVE SUITE 200E
BROOKFIELD WI
53005-4423
US

V. Phone/Fax

Practice location:
  • Phone: 262-782-4270
  • Fax: 262-784-9319
Mailing address:
  • Phone: 262-782-4270
  • Fax: 262-784-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number26997
License Number StateWI

VIII. Authorized Official

Name: DR. THOMAS A JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 262-782-4270