Provider Demographics
NPI:1629368337
Name:PEDIATRIC REHABILITATION MEDICINE ASSOCIATES,LLC
Entity Type:Organization
Organization Name:PEDIATRIC REHABILITATION MEDICINE ASSOCIATES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOBERG-WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-527-1998
Mailing Address - Street 1:18970 CAVENDISH RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-8159
Mailing Address - Country:US
Mailing Address - Phone:262-527-1998
Mailing Address - Fax:866-562-3609
Practice Address - Street 1:3333 N. MAYFAIR RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3219
Practice Address - Country:US
Practice Address - Phone:262-527-1998
Practice Address - Fax:866-562-3609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI324830202081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Single Specialty