Basic Information
| Provider Information | |||||||||
| NPI: | 1780812925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOBEN | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | MARIA BETHENIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149555990 | ||||||||
| FaxNumber: | 4149556282 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149555990 | ||||||||
| FaxNumber: | 4149556282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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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 | 208600000X | 2009014205 | MO | N | Allopathic & Osteopathic Physicians | Surgery | 208200000X | 66949 | WI | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1780812925 | 05 | WI | MEDICAID |