Healthcare Provider Details

I. General information

NPI: 1922052299
Provider Name (Legal Business Name): JEROME L GOTTSCHALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL BASED @ FROEDTERT HOSP. 9200 WEST WISCONSIN AVENUE
MILWAUKEE WI
53226
US

IV. Provider business mailing address

638 N 18TH ST PO BOX 2178
MILWAUKEE WI
53233-2121
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3666
  • Fax:
Mailing address:
  • Phone: 414-937-6231
  • Fax: 414-933-6803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number22688
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: