1659747194 NPI number — MILWAUKEE MEDICAL WEIGHT LOSS & MEDISPA, INC.

Table of content: (NPI 1659747194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659747194 NPI number — MILWAUKEE MEDICAL WEIGHT LOSS & MEDISPA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILWAUKEE MEDICAL WEIGHT LOSS & MEDISPA, INC.
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:
1659747194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8575 W FOREST HOME AVE
Provider Second Line Business Mailing Address:
SUITE 170
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53228-3469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-616-3535
Provider Business Mailing Address Fax Number:
414-427-6338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8575 W FOREST HOME AVE
Provider Second Line Business Practice Location Address:
SUITE 170
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53228-3469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-616-3535
Provider Business Practice Location Address Fax Number:
414-427-6338
Provider Enumeration Date:
08/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RAMANUJAM
Authorized Official First Name:
SANDEEP
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
414-616-3535

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  6307-33 , 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)





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