Healthcare Provider Details

I. General information

NPI: 1063433977
Provider Name (Legal Business Name): AFFILIATED HEALTH OF WISCONSIN LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 N 76TH ST SUITE 105
WAUWATOSA WI
53213-1137
US

IV. Provider business mailing address

2626 N 76TH ST SUITE 105
WAUWATOSA WI
53213-1137
US

V. Phone/Fax

Practice location:
  • Phone: 414-774-7794
  • Fax: 414-607-3971
Mailing address:
  • Phone: 414-774-7794
  • Fax: 414-607-3971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: JAY L MACKMAN
Title or Position: DIRECTOR
Credential: DDS
Phone: 414-476-9400