Basic Information
| Provider Information | |||||||||
| NPI: | 1851337646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEEKEN | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16130 SIESTA LN | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530053246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143653210 | ||||||||
| FaxNumber: | 4143653225 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532132504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144546600 | ||||||||
| FaxNumber: | 4144546522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 12/09/2011 | ||||||||
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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 | 2084P0802X | 27956 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0800X | 27956 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 31368000 | 05 | WI | MEDICAID |