Healthcare Provider Details

I. General information

NPI: 1841465739
Provider Name (Legal Business Name): THOMAS G. FENSKE M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY SUITE 925
MILWAUKEE WI
53215-3669
US

IV. Provider business mailing address

2801 W KINNICKINNIC RIVER PKWY SUITE 925
MILWAUKEE WI
53215-3669
US

V. Phone/Fax

Practice location:
  • Phone: 414-385-2499
  • Fax: 414-385-2748
Mailing address:
  • Phone: 414-385-2499
  • Fax: 414-385-2748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number3459-033
License Number StateWI

VIII. Authorized Official

Name: DR. THOMAS G FENSKE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 414-385-2499