Healthcare Provider Details

I. General information

NPI: 1114900677
Provider Name (Legal Business Name): LAURIE A KABINS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N LAKE DR
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

4425 N PORT WASHINGTON RD ATTN: CSMCP CLINIC CREDENTIALING
GLENDALE WI
53212-1082
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-1075
  • Fax:
Mailing address:
  • Phone: 414-326-2378
  • Fax: 414-326-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number38287-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: