Basic Information
| Provider Information | |||||||||
| NPI: | 1528296753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORALIC | ||||||||
| FirstName: | JASNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 788 N JEFFERSON ST | ||||||||
| Address2: | SUITE 300/ATTN. KAAREN BUTZEN | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532023718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142728950 | ||||||||
| FaxNumber: | 4142720859 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 N LAKE DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142987233 | ||||||||
| FaxNumber: | 4142987229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 62416-20 | WI | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 62416-20 | WI | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1528296753 | 05 | WI | MEDICAID |