Basic Information
| Provider Information | |||||||||
| NPI: | 1013220185 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL A. DIDION D.O.,S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 MANDAN DR | ||||||||
| Address2: | |||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531884663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625491462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3305 S 20TH ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143842100 | ||||||||
| FaxNumber: | 4143842700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2010 | ||||||||
| LastUpdateDate: | 07/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | DIDION | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2625491462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 19384 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 30032800 | 05 | WI | MEDICAID |