1194992404 NPI number — MILWAUKEE HEALTH SERVICES SYSTEM, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194992404 NPI number — MILWAUKEE HEALTH SERVICES SYSTEM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILWAUKEE HEALTH SERVICES SYSTEM, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MADISON EAST COMPREHENSIVE TREATMENT CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194992404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6183 PASEO DEL NORTE, STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92011-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-259-2288
Provider Business Mailing Address Fax Number:
608-242-1166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5109 WORLD DAIRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53718-3807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-242-0220
Provider Business Practice Location Address Fax Number:
608-242-1166
Provider Enumeration Date:
05/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FARLEY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
PHILLIP
Authorized Official Title or Position:
VP & SECRETARY
Authorized Official Telephone Number:
615-861-6000

Provider Taxonomy Codes

  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 42225600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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