=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497958839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURTON A WAISBREN MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3077 N MAYFAIR RD STE 100
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53222-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-771-5900
-----------------------------------------------------
Fax | 414-771-4908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3077 N MAYFAIR RD STE 100
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53222-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-771-5900
-----------------------------------------------------
Fax | 414-771-4908
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BURTON A. WAISBREN I
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 414-771-5900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 11016
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 11016
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------