MEDICARE: GREAT LAKES FOOT & ANKLE OF GREATER MILWAUKEE

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	261QP1100X	Podiatric Clinic/Center

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
2	WI1772	OTHER	WI	PTAN

General Provider Information

NPI Number	:	1316101595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES FOOT & ANKLE OF GREATER MILWAUKEE

Provider Business Mailing Address
First Line	:	8153 S 27TH ST
Second Line	:	400
City	:	FRANKLIN
State	:	WI
Zip	:	53132-9549
Country	:	US
Telephone Number	:	414-761-0981
Fax Number	:

Provider Business Practice Location Address
First Line	:	8153 S 27TH ST
Second Line	:	400
City	:	FRANKLIN
State	:	WI
Zip	:	53132-9549
Country	:	US
Telephone Number	:	414-761-0981
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. ROBERT D MATTEUCCI
Credential	:	D.P.M.
Telephone Number	:	414-761-0981

Provider Enumeration Date	:	07/16/2008
Last Update Date	:	12/27/2010

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