Healthcare Provider Details

I. General information

NPI: 1801979885
Provider Name (Legal Business Name): NICHOLAS KETCHUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10750 W HOWARD AVE
GREENFIELD WI
53228-1321
US

IV. Provider business mailing address

10750 W HOWARD AVE
GREENFIELD WI
53228-1321
US

V. Phone/Fax

Practice location:
  • Phone: 414-460-3195
  • Fax:
Mailing address:
  • Phone: 414-460-3195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number51705
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: