MEDICARE: GERLYN M BRASIC MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	44039	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033104427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERLYN M BRASIC MD

Provider Business Mailing Address
First Line	:	191 THEATER ROAD
Second Line	:
City	:	ONALASKA
State	:	WI
Zip	:	54650-8679
Country	:	US
Telephone Number	:	608-392-5025
Fax Number	:	608-392-5788

Provider Business Practice Location Address
First Line	:	191 THEATER ROAD
Second Line	:
City	:	ONALASKA
State	:	WI
Zip	:	54650-8679
Country	:	US
Telephone Number	:	608-392-5025
Fax Number	:	608-392-5788

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	01/24/2012

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