Basic Information
| Provider Information | |||||||||
| NPI: | 1053686493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUSTER | ||||||||
| FirstName: | MELANIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 FINANCIAL PL | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427014470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707690110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 611 VETERANS AVE UNIT 106 | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530902559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623534460 | ||||||||
| FaxNumber: | 2623534461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2012 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 70643-20 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1053686493 | 05 | WI | MEDICAID |