Basic Information
| Provider Information | |||||||||
| NPI: | 1215067665 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATTIS MEDICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6040 W LISBON AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532102116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144479890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6040 W LISBON AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532102116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144479890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 11/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | PATTIS | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4144479890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37017-020 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34522400 | 05 | WI | MEDICAID |