Basic Information
| Provider Information | |||||||||
| NPI: | 1053408203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAFI MEDICAL CENTER SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4555 W SCHROEDER DR | ||||||||
| Address2: | #170 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532231475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143653210 | ||||||||
| FaxNumber: | 4143653225 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 W NORTH AVE | ||||||||
| Address2: | #200 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143871000 | ||||||||
| FaxNumber: | 4142871010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHAFI | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4142871000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32686800 | 05 | WI | MEDICAID |