Healthcare Provider Details

I. General information

NPI: 1134208820
Provider Name (Legal Business Name): BETSY LYNNE MANOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 HOSPITAL RD
NEW RICHMOND WI
54017-1449
US

IV. Provider business mailing address

1121 E NORTH AVE COLUMBIA-ST. MARY'S FAMILY MEDICINE CENTER
MILWAUKEE WI
53212-3515
US

V. Phone/Fax

Practice location:
  • Phone: 715-243-3400
  • Fax: 414-267-3894
Mailing address:
  • Phone: 414-267-6500
  • Fax: 414-267-3894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49651
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: