Basic Information
| Provider Information | |||||||||
| NPI: | 1184654725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORGENSEN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 788 N JEFFERSON ST | ||||||||
| Address2: | SUITE 300/ATTN. KAAREN BUTZEN | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532023718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142728950 | ||||||||
| FaxNumber: | 4142720859 | ||||||||
| Practice Location | |||||||||
| Address1: | 13133 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE G18 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530972419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622435000 | ||||||||
| FaxNumber: | 2622435317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31133 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1184654725 | 05 | WI | MEDICAID |