Healthcare Provider Details

I. General information

NPI: 1669715108
Provider Name (Legal Business Name): BROOKE ELIZABETH PASSOLT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E NORTH AVE COLUMBIA ST MARYS FAMILY MEDICINE
MILWAUKEE WI
53212-3515
US

IV. Provider business mailing address

1121 E NORTH AVE COLUMBIA ST MARYS FAMILY MEDICINE
MILWAUKEE WI
53212-3515
US

V. Phone/Fax

Practice location:
  • Phone: 414-267-6500
  • Fax: 414-267-3892
Mailing address:
  • Phone: 414-267-6500
  • Fax: 414-267-3892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number65361-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: