Provider Demographics
NPI:1487152104
Name:MAPLE MEDICAL SC
Entity type:Organization
Organization Name:MAPLE MEDICAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOSTETLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-875-5070
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-0474
Mailing Address - Country:US
Mailing Address - Phone:877-307-3226
Mailing Address - Fax:866-384-9486
Practice Address - Street 1:2428 N GRANDVIEW BLVD STE 102
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6906
Practice Address - Country:US
Practice Address - Phone:877-307-3226
Practice Address - Fax:877-307-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-28
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty