Healthcare Provider Details

I. General information

NPI: 1780675165
Provider Name (Legal Business Name): JACOB C FRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KK RIVER PKWY SUITE 930
MILWAUKEE WI
53215-3669
US

IV. Provider business mailing address

3003 W GOOD HOPE RD
MILWAUKEE WI
53209-2042
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-5111
  • Fax:
Mailing address:
  • Phone: 414-352-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number23052
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: