Provider Demographics
NPI:1740262179
Name:HALE, LANNY B (MD)
Entity type:Individual
Prefix:DR
First Name:LANNY
Middle Name:B
Last Name:HALE
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 1:20350 WATER TOWER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3558
Mailing Address - Country:US
Mailing Address - Phone:262-789-9029
Mailing Address - Fax:262-789-9069
Practice Address - Street 1:20350 WATER TOWER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-3558
Practice Address - Country:US
Practice Address - Phone:262-789-9029
Practice Address - Fax:262-789-9069
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20207174400000X
AZ23821174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000187140Medicare ID - Type Unspecified
WIB53348Medicare UPIN