Provider Demographics
NPI:1497958839
Name:BURTON A WAISBREN MD SC
Entity Type:Organization
Organization Name:BURTON A WAISBREN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAISBREN
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:414-771-5900
Mailing Address - Street 1:3077 N MAYFAIR RD
Mailing Address - Street 2:STE 100
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4305
Mailing Address - Country:US
Mailing Address - Phone:414-771-5900
Mailing Address - Fax:414-771-4908
Practice Address - Street 1:3077 N MAYFAIR RD
Practice Address - Street 2:STE 100
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4305
Practice Address - Country:US
Practice Address - Phone:414-771-5900
Practice Address - Fax:414-771-4908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11016207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
131754002293OtherHUMANA
WI11016OtherLICENSE NUMBER
2784552OtherAETNA MEDICARE
0004299533OtherAETNA
1317540002293OtherHUMANA
0004299533OtherAETNA
1317540002293OtherHUMANA
0004299533OtherAETNA