Provider Demographics
NPI:1487605853
Name:BROTZMAN, GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:BROTZMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 E NORTH AVE
Mailing Address - Street 2:COLUMBIA-ST. MARY'S FAMILY PRACTICE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3515
Mailing Address - Country:US
Mailing Address - Phone:414-267-6500
Mailing Address - Fax:414-267-3895
Practice Address - Street 1:1121 E NORTH AVE
Practice Address - Street 2:COLUMBIA-ST. MARY'S FAMILY PRACTICE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3515
Practice Address - Country:US
Practice Address - Phone:414-267-6500
Practice Address - Fax:414-267-3895
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000111JOtherHUMANA
WI1487605853Medicaid
WI1487605853Medicaid
002000111JOtherHUMANA