Healthcare Provider Details

I. General information

NPI: 1205883766
Provider Name (Legal Business Name): PETER A HENRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E WISCONSIN AVE SUITE 2100
MILWAUKEE WI
53202-4815
US

IV. Provider business mailing address

111 E WISCONSIN AVE SUITE 2100
MILWAUKEE WI
53202-4815
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6700
  • Fax:
Mailing address:
  • Phone: 414-290-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number227795
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number51947-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036113654
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: