Provider Demographics
NPI:1780945857
Name:BREWER, MICHAEL ALLEN (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:BREWER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-326-2218
Mailing Address - Fax:
Practice Address - Street 1:3056 S KINNICKINNIC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-2583
Practice Address - Country:US
Practice Address - Phone:414-769-4900
Practice Address - Fax:414-769-4910
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64371207Q00000X
IL125061068390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780945857Medicaid