Basic Information
| Provider Information | |||||||||
| NPI: | 1568732378 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOBILE MEDICAL SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 146 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PEWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530723410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626911000 | ||||||||
| FaxNumber: | 2622645429 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PEWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530723410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626911000 | ||||||||
| FaxNumber: | 2622645429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2012 | ||||||||
| LastUpdateDate: | 07/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | STOLLENWERK | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2626911000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Acupuncturist | 343900000X | N | Transportation Services | Non-emergency Medical Transport (VAN) | 253Z00000X | N | Agencies | In Home Supportive Care | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 100021548 | 05 | WI | MEDICAID |