Provider Demographics
NPI:1104922525
Name:EWING, MICHAEL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:EWING
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 1:3734 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3153
Mailing Address - Country:US
Mailing Address - Phone:414-344-6111
Mailing Address - Fax:414-344-2191
Practice Address - Street 1:3734 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3153
Practice Address - Country:US
Practice Address - Phone:414-344-6111
Practice Address - Fax:414-344-2191
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI279660202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30798300Medicaid
000173725Medicare ID - Type Unspecified
E85751Medicare UPIN