Provider First Line Business Practice Location Address: 
604 N 16TH ST
    Provider Second Line Business Practice Location Address: 
CRAMER HALL 215
    Provider Business Practice Location Address City Name: 
MILWAUKEE
    Provider Business Practice Location Address State Name: 
WI
    Provider Business Practice Location Address Postal Code: 
53233-2117
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-288-1400
    Provider Business Practice Location Address Fax Number: 
414-288-6079
    Provider Enumeration Date: 
10/19/2017