Basic Information
| Provider Information | |||||||||
| NPI: | 1447365614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOEMI A PRIETO MD SC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHEASTERN PEDIATRIC & ADOLESCENT MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1126 S. 70TH ST | ||||||||
| Address2: | N500 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144554780 | ||||||||
| FaxNumber: | 4144752936 | ||||||||
| Practice Location | |||||||||
| Address1: | 8532 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532221827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144636640 | ||||||||
| FaxNumber: | 4144636743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/16/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRIETO | ||||||||
| AuthorizedOfficialFirstName: | NOEMI | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4144636640 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 26529 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 31529500 | 05 | WI | MEDICAID | 32466900 | 05 | WI | MEDICAID | 34437400 | 05 | WI | MEDICAID | 30718400 | 05 | WI | MEDICAID |