Basic Information
| Provider Information | |||||||||
| NPI: | 1568500650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREITENFELD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 4TH AVENUE | ||||||||
| Address2: | PO BOX 336 | ||||||||
| City: | SHELL L AKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154682711 | ||||||||
| FaxNumber: | 7154682727 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | SHELL L AKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154682711 | ||||||||
| FaxNumber: | 7154682727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207Q00000X | 03-023 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 42906200 | 05 | WI | MEDICAID |