MEDICARE: ADULT & ADOLESCENT TRT. CTR.

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	2084P0800X	Psychiatry Physician	15620	WI

General Provider Information

NPI Number	:	1124286430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADULT & ADOLESCENT TRT. CTR.

Provider Business Mailing Address
First Line	:	5225 N IRONWOOD RD
Second Line	:	S102
City	:	GLENDALE
State	:	WI
Zip	:	53217-4909
Country	:	US
Telephone Number	:	414-332-0552
Fax Number	:

Provider Business Practice Location Address
First Line	:	5225 N IRONWOOD RD
Second Line	:	S102
City	:	GLENDALE
State	:	WI
Zip	:	53217-4909
Country	:	US
Telephone Number	:	414-332-0552
Fax Number	:	414-962-4356

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEFFREY W WILSON
Credential	:	M.D.
Telephone Number	:	414-332-0552

Provider Enumeration Date	:	05/23/2008
Last Update Date	:	05/23/2008

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