Healthcare Provider Details

I. General information

NPI: 1063473973
Provider Name (Legal Business Name): MICHAEL C WALTERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 NEW PINERY RD
PORTAGE WI
53901-9240
US

IV. Provider business mailing address

2817 NEW PINERY ROAD DIVINE SAVIOR HEALTHCARE
PORTAGE WI
53901-0387
US

V. Phone/Fax

Practice location:
  • Phone: 608-745-5689
  • Fax: 608-742-6098
Mailing address:
  • Phone: 608-745-5689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number43499
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: