Basic Information
| Provider Information | |||||||||
| NPI: | 1639153646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENCK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530054266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627874026 | ||||||||
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| Practice Location | |||||||||
| Address1: | 835 S VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204330111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35.053347 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 25114-020 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 050026083 | 01 | RAIL ROAD MEDICARE | OTHER | 30448500 | 05 | WI | MEDICAID |