Provider Demographics
NPI:1891159612
Name:BREEZE-BALDAUF, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BREEZE-BALDAUF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 N RIVERCENTER DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3978
Mailing Address - Country:US
Mailing Address - Phone:414-283-8444
Mailing Address - Fax:414-274-5611
Practice Address - Street 1:1575 N RIVERCENTER DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-283-8444
Practice Address - Fax:414-274-5611
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100073230Medicaid