Provider Demographics
NPI:1902845282
Name:BEUTLER, SELENA RAE (MD)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:RAE
Last Name:BEUTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 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:2006-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47522-020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI003OtherBCBS
WI38424900Medicaid
WI38424900Medicaid
WII52985Medicare UPIN
WI025001940Medicare PIN