Healthcare Provider Details

I. General information

NPI: 1659784940
Provider Name (Legal Business Name): PETER J POLEWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 PORT WASHINGTON RD
GRAFTON WI
53024-9201
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 262-329-1000
  • Fax:
Mailing address:
  • Phone: 143-892-1314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number65955
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: