MEDICARE: DR. KSENIJA MODRIC JEDNACAK M.D.

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	207L00000X	Anesthesiology Physician	47908-020	WI

General Provider Information

NPI Number	:	1750452801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KSENIJA MODRIC JEDNACAK M.D.

Provider Business Mailing Address
First Line	:	6726 CEDAR ST
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-3254
Country	:	US
Telephone Number	:	414-774-4074
Fax Number	:	414-774-0471

Provider Business Practice Location Address
First Line	:	6726 CEDAR ST
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-3254
Country	:	US
Telephone Number	:	414-774-4074
Fax Number	:	414-774-0471

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

Provider Enumeration Date	:	11/12/2006
Last Update Date	:	02/06/2014

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