Healthcare Provider Details

I. General information

NPI: 1649216045
Provider Name (Legal Business Name): JODI L BREHM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODI L GROSSMAN MD

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 75TH ST
KENOSHA WI
53142
US

IV. Provider business mailing address

10400 75TH ST
KENOSHA WI
53142-7884
US

V. Phone/Fax

Practice location:
  • Phone: 262-648-5600
  • Fax: 262-948-5735
Mailing address:
  • Phone: 262-648-5600
  • Fax: 262-948-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036112238
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number52096
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: