Healthcare Provider Details

I. General information

NPI: 1447811633
Provider Name (Legal Business Name): NWSC WI DR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 N MAYFAIR RD STE 304
MILWAUKEE WI
53226-3255
US

IV. Provider business mailing address

1233 N MAYFAIR RD STE 304
MILWAUKEE WI
53226-3255
US

V. Phone/Fax

Practice location:
  • Phone: 414-257-3322
  • Fax: 414-257-3364
Mailing address:
  • Phone: 414-257-3322
  • Fax: 414-257-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: GAIL ODEN
Title or Position: ADMINISTRATOR
Credential: CASC, MBA
Phone: 414-257-3322