MEDICARE: AFFILIATED HEALTH OF WISCONSIN LTD.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	225100000X	Physical Therapist
2	2471C3401X	Computed Tomography Radiologic Technologist
3	363A00000X	Physician Assistant
4	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1063433977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFILIATED HEALTH OF WISCONSIN LTD.

Provider Business Mailing Address
First Line	:	2626 N 76TH ST
Second Line	:	SUITE 105
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-1137
Country	:	US
Telephone Number	:	414-774-7794
Fax Number	:	414-607-3971

Provider Business Practice Location Address
First Line	:	2626 N 76TH ST
Second Line	:	SUITE 105
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-1137
Country	:	US
Telephone Number	:	414-774-7794
Fax Number	:	414-607-3971

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JAY L MACKMAN
Credential	:	DDS
Telephone Number	:	414-476-9400

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	08/25/2023

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