Provider Demographics
NPI:1841391158
Name:BUCKHOLDT, MICHAEL A (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BUCKHOLDT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 N 86TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2835 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5531
Practice Address - Country:US
Practice Address - Phone:262-574-5185
Practice Address - Fax:262-574-5193
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5390024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00580096Medicare PIN
WI000580094Medicare PIN
WI832070034Medicare PIN
WI0002-83042Medicare PIN