Healthcare Provider Details

I. General information

NPI: 1689174948
Provider Name (Legal Business Name): CHARLES POTTER MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 N 51ST ST STE P309
MILWAUKEE WI
53210-1645
US

IV. Provider business mailing address

3070 N 51ST ST STE P309
MILWAUKEE WI
53210-1645
US

V. Phone/Fax

Practice location:
  • Phone: 414-447-7330
  • Fax: 414-447-1070
Mailing address:
  • Phone: 414-447-7330
  • Fax: 414-447-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number41829
License Number StateWI

VIII. Authorized Official

Name: CHARLES POTTER
Title or Position: OWNER
Credential: MD
Phone: 262-825-8984