Basic Information
| Provider Information | |||||||||
| NPI: | 1154393833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSCHEK | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | N17 W24100 RIVERWOOD DR | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES, INC. | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629284100 | ||||||||
| FaxNumber: | 2629285835 | ||||||||
| Practice Location | |||||||||
| Address1: | 1185 CORPORATE CENTER DRIVE | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES, INC. | ||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629288400 | ||||||||
| FaxNumber: | 2629288484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 41423 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 41423 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 34257100 | 05 | WI | MEDICAID |