Healthcare Provider Details

I. General information

NPI: 1619966496
Provider Name (Legal Business Name): RICHARD A PIRCON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 N LAKE DR ATTN: PERINATAL ASSESSMENT CENTER
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 414-291-1714
  • Fax: 414-291-1744
Mailing address:
  • Phone: 414-291-1714
  • Fax: 414-291-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number30244
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: