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General NPI Number Information
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NPI Number | 1154821387
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Entity Type | Organization
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Legal Business Name | MAYVILLE FAMILY PRACTICE LLC
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Dates
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Enumeration Date | 02/14/2018
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Last Update Date | 08/25/2021
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Provider Practice Location Address
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Address Line | 5595 COUNTY ROAD Z
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City | WEST BEND
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State | WI
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Zip | 53095-9224
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Country | US
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Telephone | 262-339-3038
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Fax |
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Provider Business Mailing Address
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Address Line | 3545 MARTHA CT
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City | WEST BEND
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State | WI
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Zip | 53095-8792
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Country | US
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Telephone | 262-339-3033
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. CHARLES EDWARD SAMMIS
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Credential | DO
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Telephone | 262-339-3033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 48218-21
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License Number State | WI
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