Provider Demographics
NPI:1871566182
Name:PHELAN, KATHLEEN M (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:PHELAN
Suffix:
Gender:F
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 WALNUT RIDGE DR
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-9317
Mailing Address - Country:US
Mailing Address - Phone:262-928-7500
Mailing Address - Fax:262-367-8744
Practice Address - Street 1:1500 WALNUT RIDGE DR
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-9317
Practice Address - Country:US
Practice Address - Phone:262-928-7500
Practice Address - Fax:262-367-8744
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI37057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32382200Medicare ID - Type Unspecified
WIG58676Medicare UPIN
WI68295Medicare ID - Type Unspecified
683750625Medicare PIN