Healthcare Provider Details

I. General information

NPI: 1679302228
Provider Name (Legal Business Name): FAIRWAY MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W67N222 EVERGREEN BLVD STE 218
CEDARBURG WI
53012-2650
US

IV. Provider business mailing address

W67N222 EVERGREEN BLVD STE 218
CEDARBURG WI
53012-2650
US

V. Phone/Fax

Practice location:
  • Phone: 262-519-7319
  • Fax: 262-450-4056
Mailing address:
  • Phone: 262-518-7319
  • Fax: 262-450-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DAVID ARTHUR SCOTTBERG
Title or Position: CO-OWNER
Credential:
Phone: 262-518-7319