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General NPI Number Information
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NPI Number | 1912290909
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Entity Type | Organization
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Legal Business Name | PROHEALTH MEDICAL GROUP INC
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Dates
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Enumeration Date | 05/24/2011
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Last Update Date | 05/24/2022
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Provider Practice Location Address
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Address Line | W165N5595 CREEKWOOD XING
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City | MENOMONEE FALLS
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State | WI
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Zip | 53051-0685
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Country | US
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Telephone | 262-373-2600
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Fax |
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Provider Business Mailing Address
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Address Line | N17W24100 RIVERWOOD DR SUITE 250
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City | WAUKESHA
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State | WI
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Zip | 53188-1177
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Country | US
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Telephone | 262-928-6225
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JIM LYONS
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Credential |
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Telephone | 262-928-7636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | 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 | 207RP1001X
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Taxonomy Name | Pulmonary Disease 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 | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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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 | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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Taxonomy #6
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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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