Provider Demographics
NPI:1275670275
Name:SKAMRA, CARLY LYNN (MD)
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:LYNN
Last Name:SKAMRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N BARKER RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5929
Mailing Address - Country:US
Mailing Address - Phone:262-785-1964
Mailing Address - Fax:262-785-0610
Practice Address - Street 1:601 N BARKER RD
Practice Address - Street 2:SUITE 110
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5929
Practice Address - Country:US
Practice Address - Phone:262-785-1964
Practice Address - Fax:262-785-0610
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60089-20207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118437OtherBCBS
WI32805700Medicaid
IL036118437Medicaid
WI32805700Medicaid