Healthcare Provider Details

I. General information

NPI: 1871693176
Provider Name (Legal Business Name): GRACE M JANIK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 N LAKE DR SUITE 501
MILWAUKEE WI
53211-4518
US

IV. Provider business mailing address

2015 E NEWPORT AVE SUITE 707
MILWAUKEE WI
53211-2984
US

V. Phone/Fax

Practice location:
  • Phone: 414-289-9668
  • Fax: 414-289-0498
Mailing address:
  • Phone: 414-289-9668
  • Fax: 414-289-0498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number27674-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: