Provider Demographics
NPI:1013220185
Name:MICHAEL A. DIDION D.O.,S.C.
Entity Type:Organization
Organization Name:MICHAEL A. DIDION D.O.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DIDION
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:262-549-1462
Mailing Address - Street 1:311 MANDAN DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-4663
Mailing Address - Country:US
Mailing Address - Phone:262-549-1462
Mailing Address - Fax:
Practice Address - Street 1:3305 S 20TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4940
Practice Address - Country:US
Practice Address - Phone:414-384-2100
Practice Address - Fax:414-384-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19384207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30032800Medicaid