Basic Information
| Provider Information | |||||||||
| NPI: | 1518404854 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEANSLATE MEDICAL GROUP OF WISCONSIN, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 CENTURY BLVD STE 307 | ||||||||
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| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372143692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154250220 | ||||||||
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| Practice Location | |||||||||
| Address1: | 377 W RIVER WOODS PKWY STE 201 | ||||||||
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| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133236880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2017 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | HUTCHISON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6154250220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
No ID Information.