Healthcare Provider Details

I. General information

NPI: 1093715856
Provider Name (Legal Business Name): BARRY KENT GIMBEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 N PORT WASHINGTON RD STE 249
MILWAUKEE WI
53217-5474
US

IV. Provider business mailing address

5150 N PORT WASHINGTON RD STE 249
MILWAUKEE WI
53217-5474
US

V. Phone/Fax

Practice location:
  • Phone: 414-964-0000
  • Fax: 414-964-2556
Mailing address:
  • Phone: 414-964-0000
  • Fax: 414-964-2556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number24375
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: