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General NPI Number Information
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NPI Number | 1326163304
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Entity Type | Individual
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Provider Name | GREGORY ALAN EKBOM MD
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Gender | Male
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 07/06/2011
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Provider Practice Location Address
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Address Line | 10400 W NORTH AVENUE #480
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City | MILWAUKEE
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State | WI
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Zip | 53226-2425
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Country | US
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Telephone | 414-778-6670
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Fax | 414-778-6672
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Provider Business Mailing Address
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Address Line | P.O. BOX 309 #480
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City | PEWAUKEE
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State | WI
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Zip | 53072-0309
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Country | US
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Telephone | 262-366-1595
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Fax | 414-778-6672
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 20232020
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License Number State | WI
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