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General NPI Number Information
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NPI Number | 1184958209
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Entity Type | Organization
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Legal Business Name | MARTIN MEN'S MEDICAL CLINIC OF WISCONSIN
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Dates
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Enumeration Date | 09/22/2009
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Last Update Date | 09/22/2009
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Provider Practice Location Address
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Address Line | 2949 N MAYFAIR RD STE 300
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City | WAUWATOSA
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State | WI
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Zip | 53222-4304
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Country | US
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Telephone | 414-454-6000
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Fax | 414-454-6420
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Provider Business Mailing Address
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Address Line | 2949 N MAYFAIR RD STE 300
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City | WAUWATOSA
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State | WI
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Zip | 53222-4304
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Country | US
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Telephone | 414-454-6000
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Fax | 414-454-6420
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DAVID MOELLER
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Credential |
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Telephone | 414-454-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 20798-020
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License Number State | WI
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