Healthcare Provider Details

I. General information

NPI: 1669854618
Provider Name (Legal Business Name): KOREY BENJAMIN KASPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N15W28300 GOLF RD
PEWAUKEE WI
53072-4800
US

IV. Provider business mailing address

N15W28300 GOLF RD
PEWAUKEE WI
53072-4800
US

V. Phone/Fax

Practice location:
  • Phone: 262-303-5055
  • Fax: 262-303-5057
Mailing address:
  • Phone: 262-303-5055
  • Fax: 262-303-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number87110-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberS4789
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number29916
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: