Healthcare Provider Details

I. General information

NPI: 1295231769
Provider Name (Legal Business Name): MICHAEL JOHN KNABEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12831 N PORT WASHINGTON RD
MEQUON WI
53097-2400
US

IV. Provider business mailing address

169 ASHLEY AVENUE ROOM 202 MAIN HOSPITAL, MSC333
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 262-643-1300
  • Fax:
Mailing address:
  • Phone: 843-792-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125.075232
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMMD.87404
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number82136
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number82136
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: