Basic Information
| Provider Information | |||||||||
| NPI: | 1033470489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREGER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4555 W SCHROEDER DR | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532231496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143653210 | ||||||||
| FaxNumber: | 4143653225 | ||||||||
| Practice Location | |||||||||
| Address1: | 7007 N RANGE LINE RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532092620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143523341 | ||||||||
| FaxNumber: | 4142474588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2012 | ||||||||
| LastUpdateDate: | 06/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 26922-20 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 30800900 | 05 | WI | MEDICAID |