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General NPI Number Information
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NPI Number | 1912929803
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Entity Type | Individual
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Provider Name | MARY L. GANZ D.O.
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Gender | Female
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Dates
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Enumeration Date | 07/23/2006
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Last Update Date | 03/14/2011
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Provider Practice Location Address
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Address Line | 1290 BETSY ROSS CT
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City | BROOKFIELD
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State | WI
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Zip | 53045-5362
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Country | US
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Telephone | 262-796-0203
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Fax |
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Provider Business Mailing Address
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Address Line | 1290 BETSY ROSS CT
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City | BROOKFIELD
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State | WI
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Zip | 53045-5362
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 29009
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License Number State | WI
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