Healthcare Provider Details

I. General information

NPI: 1073547949
Provider Name (Legal Business Name): JERREL L STANLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N112 W 17975 MEQUON ROAD
GERMANTOWN WI
53022
US

IV. Provider business mailing address

3003 W GOOD HOPE ROAD
MILWAUKEE WI
53209
US

V. Phone/Fax

Practice location:
  • Phone: 262-532-7600
  • Fax: 262-532-7602
Mailing address:
  • Phone: 414-352-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22544
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: