Basic Information
| Provider Information | |||||||||
| NPI: | 1780647263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAILLOUX | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | MS 958 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142667615 | ||||||||
| FaxNumber: | 4142666238 | ||||||||
| Practice Location | |||||||||
| Address1: | 5433 W FOND DU LAC AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532161382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142778900 | ||||||||
| FaxNumber: | 4142778939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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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 | 208000000X | 0101231620 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 53698-20 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5903026 | 05 | NC | MEDICAID | 010217504 | 05 | VA | MEDICAID | 1780647263 | 05 | WI | MEDICAID |