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General NPI Number Information
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NPI Number | 1528344819
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Entity Type | Organization
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Legal Business Name | MARK B. SMUCKLER MD LTD
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Dates
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Enumeration Date | 10/31/2011
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Last Update Date | 10/31/2011
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Provider Practice Location Address
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Address Line | 155 E SILVER SPRING DR 203
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City | MILWAUKEE
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State | WI
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Zip | 53217-4704
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Country | US
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Telephone | 414-332-2450
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Fax | 414-332-1390
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Provider Business Mailing Address
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Address Line | 155 E SILVER SPRING DR 203
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City | MILWAUKEE
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State | WI
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Zip | 53217-4704
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Country | US
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Telephone | 414-332-2450
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Fax | 414-332-1390
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK B SMUCKLER
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Credential | M.D.
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Telephone | 414-332-2450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 16139
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 16139
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License Number State | WI
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