MEDICARE: MARGARET I SCOTTBERG PA

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	363AS0400X	Surgical Physician Assistant	2298-23	WI
2	363A00000X	Physician Assistant	2298	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2298-23	OTHER	WI	STATE LICENSE

General Provider Information

NPI Number	:	1669635868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARGARET I SCOTTBERG PA

Provider Business Mailing Address
First Line	:	4425 N PORT WASHINGTON RD
Second Line	:	CLINIC CREDENTIALING
City	:	GLENDALE
State	:	WI
Zip	:	53212-1082
Country	:	US
Telephone Number	:	414-326-2218
Fax Number	:	414-326-2208

Provider Business Practice Location Address
First Line	:	2301 N LAKE DR RM 1577
Second Line	:	COLUMBIA ST MARY'S MS CLINIC
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4508
Country	:	US
Telephone Number	:	414-291-1771
Fax Number	:	414-291-1781

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

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	05/02/2014

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Directions to “ MARGARET I SCOTTBERG PA” Practice Location

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