Healthcare Provider Details

I. General information

NPI: 1700144698
Provider Name (Legal Business Name): REBECCA GAYLE MARTINIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 S MOORLAND RD FL 3
NEW BERLIN WI
53151-7494
US

IV. Provider business mailing address

CHILDREN'S URGENT CARE 9000 W WISCONSIN AVENUE # MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-7599
  • Fax: 262-432-7694
Mailing address:
  • Phone: 414-266-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ4630
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberQ4630
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number71893-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: