Healthcare Provider Details

I. General information

NPI: 1750460200
Provider Name (Legal Business Name): CHARLES H TIBER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N LAKE DR #100
MILWAUKEE WI
53211-4528
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 414-298-7250
  • Fax:
Mailing address:
  • Phone: 414-319-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number23272
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: