Basic Information
| Provider Information | |||||||||
| NPI: | 1811945942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENTINE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 N PORT WASHINGTON RD | ||||||||
| Address2: | ATTN: CLINIC CREDENTIALING | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204574438 | ||||||||
| FaxNumber: | 9204576748 | ||||||||
| Practice Location | |||||||||
| Address1: | 1703 N TAYLOR DR | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530811933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204574438 | ||||||||
| FaxNumber: | 9204576748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 06/12/2012 | ||||||||
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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 | 40128-020 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33332800 | 05 | WI | MEDICAID |