=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861479479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK C MCDONALD P.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2005
-----------------------------------------------------
Last Update Date | 07/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8700 W WATERTOWN PLANK RD ORTHOPAEDIC SURGERY
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-805-8602
-----------------------------------------------------
Fax | 414-805-7171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | S68W15500 JANESVILLE RD
-----------------------------------------------------
City | MUSKEGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53150-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-422-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1305-023
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------