Provider Demographics
NPI:1689091316
Name:WHALEN, WILLIAM T IV (CO)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:T
Last Name:WHALEN
Suffix:IV
Gender:M
Credentials:CO
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Mailing Address - Street 1:5027 GREEN BAY RD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1771
Mailing Address - Country:US
Mailing Address - Phone:262-654-4300
Mailing Address - Fax:262-654-4305
Practice Address - Street 1:5027 GREEN BAY RD
Practice Address - Street 2:SUITE 124
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1771
Practice Address - Country:US
Practice Address - Phone:262-654-4300
Practice Address - Fax:262-654-4305
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL213000315335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier