Provider Demographics
NPI:1629157425
Name:CROMWELL, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CROMWELL
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 1:2311 N PROSPECT
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211
Mailing Address - Country:US
Mailing Address - Phone:414-319-3000
Mailing Address - Fax:
Practice Address - Street 1:2311 N PROSPECT
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211
Practice Address - Country:US
Practice Address - Phone:414-319-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20378207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30139400Medicaid
WI30139400Medicaid