=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811601776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PPM WISCONSIN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2023
-----------------------------------------------------
Last Update Date | 06/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | W175N11117 STONEWOOD DR STE 100
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53022-6505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-253-6598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W175N11117 STONEWOOD DR STE 100
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53022-6505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-253-6598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | AMBER L TUELLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-207-2726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------