Healthcare Provider Details

I. General information

NPI: 1801847249
Provider Name (Legal Business Name): ELLEN L BLANK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC GASTROENTEROLOGY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC GASTROENTEROLOGY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3690
  • Fax: 414-266-3676
Mailing address:
  • Phone: 414-266-3690
  • Fax: 414-266-3676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number22293
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: