Provider Demographics
NPI:1326163304
Name:EKBOM, GREGORY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:EKBOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 309
Mailing Address - Street 2:#480
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-0309
Mailing Address - Country:US
Mailing Address - Phone:262-366-1595
Mailing Address - Fax:414-778-6672
Practice Address - Street 1:10400 W NORTH AVENUE
Practice Address - Street 2:#480
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-2425
Practice Address - Country:US
Practice Address - Phone:414-778-6670
Practice Address - Fax:414-778-6672
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI20232020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI020014187OtherRAILROAD MEDICARE
WI21261700Medicaid
WI000101740Medicare PIN
WI21261700Medicaid