Healthcare Provider Details

I. General information

NPI: 1578069654
Provider Name (Legal Business Name): RYAN STEFANCZYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
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:
Mailing address:
  • Phone: 262-303-5055
  • Fax: 262-303-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number73852-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: