Healthcare Provider Details

I. General information

NPI: 1659489789
Provider Name (Legal Business Name): SCOTT R PESCHKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 KILEY WAY
PLYMOUTH WI
53073-5020
US

IV. Provider business mailing address

2600 KILEY WAY
PLYMOUTH WI
53073-5020
US

V. Phone/Fax

Practice location:
  • Phone: 920-449-7000
  • Fax:
Mailing address:
  • Phone: 920-449-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25391
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: