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NPI Code Detail

MEDICARE: SAMANTHA ANN BROGHAMMER RD

MEDICARE: SAMANTHA ANN BROGHAMMER RD
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
1133V00000XRegistered Dietitian86095627WI

General Provider Information

NPI Number : 1497365720
Entity Type Code : Individual
Provider Name (Legal Business Name) : SAMANTHA ANN BROGHAMMER RD
Provider Business Mailing Address
First Line : 344A N 68TH ST
Second Line :
City : WAUWATOSA
State : WI
Zip : 53213-3931
Country : US
Telephone Number : 920-946-2855
Fax Number :
Provider Business Practice Location Address
First Line : 4600 W SCHROEDER DR
Second Line :
City : BROWN DEER
State : WI
Zip : 53223-6458
Country : US
Telephone Number : 414-865-2500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/02/2020
Last Update Date : 08/02/2020

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