Provider First Line Business Practice Location Address: 
5000 W NATIONAL AVE
    Provider Second Line Business Practice Location Address: 
RESEARCH DIVISION/151 VA MED CENTER/MED COLLEGE OF WI
    Provider Business Practice Location Address City Name: 
MILWAUKEE
    Provider Business Practice Location Address State Name: 
WI
    Provider Business Practice Location Address Postal Code: 
53295
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-384-2000
    Provider Business Practice Location Address Fax Number: 
414-382-5320
    Provider Enumeration Date: 
03/03/2015