Basic Information
| Provider Information | |||||||||
| NPI: | 1366959447 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDEPENDENT PHYSICIANS OF WISCONSIN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5434 W CAPITOL DR STE 3 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532162298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148750505 | ||||||||
| FaxNumber: | 4148756786 | ||||||||
| Practice Location | |||||||||
| Address1: | 5434 W CAPITOL DR STE 3 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532162298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148750505 | ||||||||
| FaxNumber: | 4148756786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2018 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
| AuthorizedOfficialMiddleName: | QASIM | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4148750505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INDEPENDENT PHYSICIANS OF WISCONSIN, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.