Healthcare Provider Details

I. General information

NPI: 1801672282
Provider Name (Legal Business Name): PHAEDRA MARIA TACHTATZIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3310
  • Fax: 414-805-3885
Mailing address:
  • Phone: 414-805-3310
  • Fax: 414-805-3885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number10-876
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number10-876
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: