Healthcare Provider Details

I. General information

NPI: 1194712455
Provider Name (Legal Business Name): TRACY A PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 W MITCHELL ST STE 300
MILWAUKEE WI
53215-1748
US

IV. Provider business mailing address

4111 W MITCHELL ST STE 300
MILWAUKEE WI
53215-1748
US

V. Phone/Fax

Practice location:
  • Phone: 414-385-8800
  • Fax:
Mailing address:
  • Phone: 414-385-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number30606
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number30606-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: