Healthcare Provider Details

I. General information

NPI: 1053810499
Provider Name (Legal Business Name): GREGORY S MILLEVILLE, MD, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 N 51ST ST STE 309
MILWAUKEE WI
53210-1661
US

IV. Provider business mailing address

3070 N 51ST ST STE 309
MILWAUKEE WI
53210-1661
US

V. Phone/Fax

Practice location:
  • Phone: 414-333-0224
  • Fax:
Mailing address:
  • Phone: 414-333-0224
  • Fax: 414-447-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number25845
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number25845-20
License Number StateWI

VIII. Authorized Official

Name: DR. GREGORY SCOTT MILLEVILLE
Title or Position: PRESIDENT
Credential: MD
Phone: 414-333-0224