Provider Demographics
NPI:1881642445
Name:GROESCHEL, MICHAEL C (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:GROESCHEL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 W OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4330
Mailing Address - Country:US
Mailing Address - Phone:414-649-6588
Mailing Address - Fax:770-237-1723
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-6588
Practice Address - Fax:770-237-1723
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1913-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI001OtherBCBS
WI024501940Medicare PIN
WIQ56197Medicare UPIN
P00475507Medicare PIN