MEDICARE: JOHN A MORTENSEN

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	231H00000X	Audiologist	365-156	WI

General Provider Information

NPI Number	:	1407802564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN A MORTENSEN

Provider Business Mailing Address
First Line	:	2255 S 108TH ST
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-1107
Country	:	US
Telephone Number	:	414-774-4200
Fax Number	:	414-774-6828

Provider Business Practice Location Address
First Line	:	2255 S 108TH ST
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-1107
Country	:	US
Telephone Number	:	414-774-4200
Fax Number	:	414-774-6828

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	05/23/2014

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