Provider Demographics
NPI:1447302492
Name:CHARLES J. WAISBREN MD S.C.
Entity type:Organization
Organization Name:CHARLES J. WAISBREN MD S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAISBREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD SC
Authorized Official - Phone:414-771-5900
Mailing Address - Street 1:3077 N MAYFAIR RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4305
Mailing Address - Country:US
Mailing Address - Phone:414-771-5900
Mailing Address - Fax:414-771-4908
Practice Address - Street 1:3077 N MAYFAIR RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4305
Practice Address - Country:US
Practice Address - Phone:414-771-5900
Practice Address - Fax:414-771-4908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25111207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1750481206OtherPERSONAL NPI #
WIAW201800OtherDEA
WIAW201800OtherDEA
WI=========OtherTAX ID