Provider Demographics
NPI:1528344819
Name:MARK B. SMUCKLER MD LTD
Entity type:Organization
Organization Name:MARK B. SMUCKLER MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMUCKLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-332-2450
Mailing Address - Street 1:155 E SILVER SPRING DR
Mailing Address - Street 2:203
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4704
Mailing Address - Country:US
Mailing Address - Phone:414-332-2450
Mailing Address - Fax:414-332-1390
Practice Address - Street 1:155 E SILVER SPRING DR
Practice Address - Street 2:203
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4704
Practice Address - Country:US
Practice Address - Phone:414-332-2450
Practice Address - Fax:414-332-1390
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK B. SMUCKLER MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16139261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30954800Medicaid
B-56726Medicare UPIN