Healthcare Provider Details

I. General information

NPI: 1508834193
Provider Name (Legal Business Name): CHARLES F KIDD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W. KINNICKINNIC RIVER PARKWAY SUITE 370
MILWAUKEE WI
53215
US

IV. Provider business mailing address

2801 W. KINNICKINNIC RIVER PARKWAY SUITE 370
MILWAUKEE WI
53215
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-6006
  • Fax: 414-672-6016
Mailing address:
  • Phone: 414-672-6006
  • Fax: 414-672-6016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number46512020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: