Healthcare Provider Details

I. General information

NPI: 1568500650
Provider Name (Legal Business Name): MICHAEL L BREITENFELD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 4TH AVENUE
SHELL L AKE WI
54871-0336
US

IV. Provider business mailing address

105 4TH AVENUE PO BOX 336
SHELL L AKE WI
54871-0336
US

V. Phone/Fax

Practice location:
  • Phone: 715-468-2711
  • Fax: 715-468-2727
Mailing address:
  • Phone: 715-468-2711
  • Fax: 715-468-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: