Healthcare Provider Details

I. General information

NPI: 1316101595
Provider Name (Legal Business Name): GREAT LAKES FOOT & ANKLE OF GREATER MILWAUKEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 12/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8153 S 27TH ST 400
FRANKLIN WI
53132-9549
US

IV. Provider business mailing address

8153 S 27TH ST 400
FRANKLIN WI
53132-9549
US

V. Phone/Fax

Practice location:
  • Phone: 414-761-0981
  • Fax:
Mailing address:
  • Phone: 414-761-0981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT D MATTEUCCI
Title or Position: MANAGER
Credential: D.P.M.
Phone: 414-761-0981