=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184671521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMAD BOTROS, M.D., S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2006
-----------------------------------------------------
Last Update Date | 01/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3070 N 51ST ST SUITE 402
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53210-1645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-871-2673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10100 N FOXKIRK DR
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53097-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | EMAD BOTROS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 414-527-5354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------