Healthcare Provider Details

I. General information

NPI: 1174653596
Provider Name (Legal Business Name): MILWAUKEE OCCUPATIONAL MEDICINE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 WEST RIVER WOODS PARKWAY SUITE 111
GLENDALE WI
53212
US

IV. Provider business mailing address

377 WEST RIVER WOODS PARKWAY SUITE 111
GLENDALE WI
53212
US

V. Phone/Fax

Practice location:
  • Phone: 414-967-0966
  • Fax: 414-967-1035
Mailing address:
  • Phone: 414-967-0966
  • Fax: 414-967-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number37148020
License Number StateWI

VIII. Authorized Official

Name: VANCE ANDREW MASCI
Title or Position: CEO
Credential: MD
Phone: 414-967-0966