1275767485 NPI number — MHS CONVENIENT CARE CLINIC

Table of content: (NPI 1275767485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275767485 NPI number — MHS CONVENIENT CARE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MHS CONVENIENT CARE CLINIC
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:
Provider Other Organization Name Type Code:
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:
1275767485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2555 N MARTIN LUTHER KING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53212-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-372-8080
Provider Business Mailing Address Fax Number:
414-372-7425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4061 N 54TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53216-1377
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-372-8080
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BOLDEN
Authorized Official First Name:
FRAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
414-372-8080

Provider Taxonomy Codes

  • Taxonomy code: 363LC1500X , with the licence number:  6282-800 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33724600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43086700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 521829 . This is a "MEDICARE UGS#" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1518005818 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32958200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42183000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44066400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33782900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32831100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 521804 . This is a "MEDICARE USG#" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 33780500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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