Provider Demographics
NPI:1447293352
Name:HUETTL, BRIAN M (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:HUETTL
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 1:111 E WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4815
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:111 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4815
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092823207P00000X
WI44708-020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI930128806OtherMEDICARE RAILROAD
IL036092823Medicaid
WI34298600Medicaid
WI930128806OtherMEDICARE RAILROAD
ILL64323Medicare ID - Type Unspecified
WI004932280Medicare ID - Type Unspecified
WI004632350Medicare ID - Type Unspecified
WI34298600Medicaid
IL036092823Medicaid