Healthcare Provider Details

I. General information

NPI: 1568732378
Provider Name (Legal Business Name): MOBILE MEDICAL SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 PARK AVE
PEWAUKEE WI
53072-3410
US

IV. Provider business mailing address

146 PARK AVE
PEWAUKEE WI
53072-3410
US

V. Phone/Fax

Practice location:
  • Phone: 262-691-1000
  • Fax: 262-264-5429
Mailing address:
  • Phone: 262-691-1000
  • Fax: 262-264-5429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: SCOTT STOLLENWERK
Title or Position: PRESIDENT
Credential:
Phone: 262-691-1000