Provider Demographics
NPI:1023064912
Name:BRESNAHAN, JILL M (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:BRESNAHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 E WEBSTER PL
Mailing Address - Street 2:#301
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4256
Mailing Address - Country:US
Mailing Address - Phone:414-272-7009
Mailing Address - Fax:414-272-6261
Practice Address - Street 1:2524 E WEBSTER PL
Practice Address - Street 2:#301
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4256
Practice Address - Country:US
Practice Address - Phone:414-272-7009
Practice Address - Fax:414-272-6261
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI38803208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32496500Medicaid
02975005Medicare ID - Type Unspecified
G84999Medicare UPIN