Basic Information
| Provider Information | |||||||||
| NPI: | 1508483140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VITAE HEALTH MEDICAL WISCONSIN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3450 OAKTON ST STE 300 | ||||||||
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| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2247778034 | ||||||||
| FaxNumber: | 2242364900 | ||||||||
| Practice Location | |||||||||
| Address1: | 6735 W BRADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532233325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2247778034 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2020 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | AMISH | ||||||||
| AuthorizedOfficialMiddleName: | MANU | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2247778034 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.