Healthcare Provider Details

I. General information

NPI: 1932368685
Provider Name (Legal Business Name): CENTER FOR STOMACH & INTESTINAL DISORDERS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2008
Last Update Date: 06/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N MAYFAIR RD STE 725
WAUWATOSA WI
53226-1533
US

IV. Provider business mailing address

2300 N MAYFAIR RD STE 725
WAUWATOSA WI
53226-1533
US

V. Phone/Fax

Practice location:
  • Phone: 414-778-1911
  • Fax: 414-778-1916
Mailing address:
  • Phone: 414-778-1911
  • Fax: 414-778-1916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number27635
License Number StateWI

VIII. Authorized Official

Name: MARY CATHERINE A GERLEMAN
Title or Position: OWNER
Credential: MD
Phone: 414-778-1911