Healthcare Provider Details

I. General information

NPI: 1528344819
Provider Name (Legal Business Name): MARK B. SMUCKLER MD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E SILVER SPRING DR 203
MILWAUKEE WI
53217-4704
US

IV. Provider business mailing address

155 E SILVER SPRING DR 203
MILWAUKEE WI
53217-4704
US

V. Phone/Fax

Practice location:
  • Phone: 414-332-2450
  • Fax: 414-332-1390
Mailing address:
  • Phone: 414-332-2450
  • Fax: 414-332-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number16139
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number16139
License Number StateWI

VIII. Authorized Official

Name: DR. MARK B SMUCKLER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 414-332-2450