Healthcare Provider Details

I. General information

NPI: 1124079975
Provider Name (Legal Business Name): MARC H GORELICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL BASED @ CHW HOSP. 9000 WEST WISCONSIN AVENUE
MILWAUKEE WI
53226
US

IV. Provider business mailing address

9000 W WISCONSIN AVE HOSPITAL BASED @ CHW HOSP.
MILWAUKEE WI
53226-3518
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number42366
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: