Healthcare Provider Details

I. General information

NPI: 1558093997
Provider Name (Legal Business Name): MR. DOMINIC PATRICK PORUBSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 S 102ND ST STE 200
WEST ALLIS WI
53227-2141
US

IV. Provider business mailing address

18700 ANITA CT
BROOKFIELD WI
53045-4229
US

V. Phone/Fax

Practice location:
  • Phone: 414-327-3000
  • Fax:
Mailing address:
  • Phone: 262-765-1012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: