Provider Demographics
NPI:1487210076
Name:FORMELLER, CHARLOTTE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:FORMELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:
Other - Last Name:MCSHARRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-337-7050
Mailing Address - Fax:414-337-7020
Practice Address - Street 1:9000 W WISCONSIN AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-337-7050
Practice Address - Fax:414-337-7020
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI76538208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1487210076Medicaid