Healthcare Provider Details

I. General information

NPI: 1528102498
Provider Name (Legal Business Name): PEDIATRIC EAR, NOSE & THROAT SPECIALISTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE SUITE 265
MILWAUKEE WI
53226-3518
US

IV. Provider business mailing address

9000 W WISCONSIN AVE SUITE 265
MILWAUKEE WI
53226-3518
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2761
  • Fax: 414-266-2766
Mailing address:
  • Phone: 414-266-2761
  • Fax: 414-266-2766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number43113
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number22968
License Number StateWI

VIII. Authorized Official

Name: DAVID J BESTE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 414-266-2761