Basic Information
| Provider Information | |||||||||
| NPI: | 1285607267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLOCH | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | N17W24100 RIVERWOOD DR | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES INC SUITE 250 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629284100 | ||||||||
| FaxNumber: | 2629285835 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 MAPLE AVE | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES | ||||||||
| City: | MUKWONAGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531498475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629281900 | ||||||||
| FaxNumber: | 2623631949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 11/09/2011 | ||||||||
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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 | 207Q00000X | 44072 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34445600 | 05 | WI | MEDICAID |