Provider Demographics
NPI:1235102286
Name:FARIS, SEAN M (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:M
Last Name:FARIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:N17 W24100 RIVERWOOD DRIVE SUITE 250
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:262-928-4100
Mailing Address - Fax:262-928-5835
Practice Address - Street 1:240 MAPLE AVENUE
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149
Practice Address - Country:US
Practice Address - Phone:262-928-1900
Practice Address - Fax:262-363-1949
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2011-11-09
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Provider Licenses
StateLicense IDTaxonomies
WI44055208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34158400Medicaid
WI006868605Medicare PIN
WIG94704Medicare UPIN