Provider Demographics
NPI:1871675264
Name:REBHOLZ, BRANDON JOHN (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JOHN
Last Name:REBHOLZ
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:ORTHOPAEDIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-7410
Mailing Address - Fax:414-805-4799
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:ORTHOPAEDIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-7410
Practice Address - Fax:414-805-4799
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51083-20207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871675264Medicaid
WIK400229628Medicare PIN
WI012950051Medicare PIN