Provider Demographics
NPI:1073790804
Name:EDLEBECK, ANNA B
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:B
Last Name:EDLEBECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:B
Other - Last Name:SHABUNINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21700 INTERTECH DR
Mailing Address - Street 2:SPRINGDALE HEALTH CENTER
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5197
Mailing Address - Country:US
Mailing Address - Phone:262-532-8300
Mailing Address - Fax:262-532-8600
Practice Address - Street 1:21700 INTERTECH DR
Practice Address - Street 2:SPRINGDALE HEALTH CENTER
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5197
Practice Address - Country:US
Practice Address - Phone:262-532-8300
Practice Address - Fax:262-532-8600
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49961207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073790804Medicaid
WI736011507Medicare PIN
WI1073790804Medicaid