Healthcare Provider Details

I. General information

NPI: 1295819118
Provider Name (Legal Business Name): NORTH SHORE PODIATRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8003 N PORT WASHINGTON RD
MILWAUKEE WI
53217-2647
US

IV. Provider business mailing address

8003 N PORT WASHINGTON RD
MILWAUKEE WI
53217-2647
US

V. Phone/Fax

Practice location:
  • Phone: 414-228-6444
  • Fax: 414-228-7005
Mailing address:
  • Phone: 414-228-6444
  • Fax: 414-228-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number658025
License Number StateWI

VIII. Authorized Official

Name: DR. CLIFFORD D GREENBAUM
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 414-228-6444