Healthcare Provider Details

I. General information

NPI: 1295127298
Provider Name (Legal Business Name): M ORTHO, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W62 N179 WASHINGTON AVE SUITE 3
CEDARBURG WI
53012-2726
US

IV. Provider business mailing address

PO BOX 410
BROOKFIELD WI
53008-0410
US

V. Phone/Fax

Practice location:
  • Phone: 262-641-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number41376
License Number StateWI

VIII. Authorized Official

Name: DR. KRISTEN MASKALA
Title or Position: OWNER
Credential: M.D.
Phone: 262-641-3700