1497091003 NPI number — MILWAUKEE MEDICAL ASSOCIATES, SC

Table of content: JACQUELINE BERKOVSKY PA (NPI 1902400153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497091003 NPI number — MILWAUKEE MEDICAL ASSOCIATES, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILWAUKEE MEDICAL ASSOCIATES, SC
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:
1497091003
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2741 W LAYTON AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-672-9940
Provider Business Mailing Address Fax Number:
414-672-9941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2741 W LAYTON AVE
Provider Second Line Business Practice Location Address:
#201
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53221-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-672-9940
Provider Business Practice Location Address Fax Number:
414-672-9941
Provider Enumeration Date:
12/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HUSNAIN
Authorized Official First Name:
FOUAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
414-672-9940

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  49355 , 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: 1295899854 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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