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General NPI Number Information
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NPI Number | 1487152104
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Entity Type | Organization
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Legal Business Name | MAPLE MEDICAL SC
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Dates
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Enumeration Date | 01/28/2018
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Last Update Date | 06/14/2021
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Provider Practice Location Address
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Address Line | 2428 N GRANDVIEW BLVD STE 102
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City | WAUKESHA
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State | WI
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Zip | 53188-6906
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Country | US
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Telephone | 877-307-3226
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Fax | 877-307-3226
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Provider Business Mailing Address
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Address Line | PO BOX 474
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City | HARTLAND
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State | WI
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Zip | 53029-0474
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Country | US
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Telephone | 877-307-3226
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Fax | 866-384-9486
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Authorized Official
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Title or Position | OWNER
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Name | HARRY HOSTETLER
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Credential | MD
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Telephone | 262-875-5070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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