Basic Information
| Provider Information | |||||||||
| NPI: | 1548248347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDALATPOUR | ||||||||
| FirstName: | MEHRAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 W CHAMBERS ST | ||||||||
| Address2: | SUITE N240A | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532101650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148744763 | ||||||||
| FaxNumber: | 4148744160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 33871-020 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31957100 | 05 | WI | MEDICAID |