Provider Demographics
NPI: | 1437136488 |
---|---|
Name: | WICHMAN, MARK T (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARK |
Middle Name: | T |
Last Name: | WICHMAN |
Suffix: | |
Gender: | M |
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: | 3003 W GOOD HOPE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | MILWAUKEE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53209-2042 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 414-352-3100 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1575 N RIVERCENTER DR |
Practice Address - Street 2: | SUITE 160 |
Practice Address - City: | MILWAUKEE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53212-3978 |
Practice Address - Country: | US |
Practice Address - Phone: | 414-274-7220 |
Practice Address - Fax: | 414-274-7227 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-29 |
Last Update Date: | 2021-11-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 37933 | 174400000X, 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | |
No | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 32253100 | Medicaid | |
WI | P00682036 | Other | RR MEDICARE |
WI | P00682036 | Other | RR MEDICARE |
WI | 32253100 | Medicaid | |
WI | 01994-0371 | Medicare PIN |