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NPI Code Detail

MEDICARE: DR. BRIAN J HETTRICK M.D.

MEDICARE: DR. BRIAN J HETTRICK 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
1207Q00000XFamily Medicine Physician41149WI

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2P00248375OTHERRAIL ROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1942262712
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BRIAN J HETTRICK M.D.
Provider Business Mailing Address
First Line : 25405 103RD ST
Second Line :
City : SALEM
State : WI
Zip : 53168-8915
Country : US
Telephone Number : 262-909-8169
Fax Number :
Provider Business Practice Location Address
First Line : 8400 WASHINGTON AVE
Second Line :
City : MOUNT PLEASANT
State : WI
Zip : 53406-3735
Country : US
Telephone Number : 262-884-4088
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/05/2006
Last Update Date : 02/13/2024

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