Basic Information
| Provider Information | |||||||||
| NPI: | 1083954630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VISITING MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 7978 FIELDING LN | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144237199 | ||||||||
| FaxNumber: | 4144237366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2013 | ||||||||
| LastUpdateDate: | 07/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | GARG | ||||||||
| AuthorizedOfficialFirstName: | ANIL | ||||||||
| AuthorizedOfficialMiddleName: | KUMAR | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4142221475 | ||||||||
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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 | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1083954630 | 05 | WI | MEDICAID |