Healthcare Provider Details

I. General information

NPI: 1336106277
Provider Name (Legal Business Name): MARIO RICCARDO COLELLA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE DEPARTMENT OF EMERGENCY MEDICINE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE DEPARTMENT OF EMERGENCY MEDICINE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-6450
  • Fax: 414-805-6464
Mailing address:
  • Phone: 414-805-6450
  • Fax: 414-805-6464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number50358
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberH0060361
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: