Basic Information
Provider Information | |||||||||
NPI: | 1598982274 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AURORA SINAI MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 945 N 12TH ST | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 53233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4142192000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 945 N 12TH ST | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 53233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4142192000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2007 | ||||||||
LastUpdateDate: | 11/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUSH | ||||||||
AuthorizedOfficialFirstName: | STEVE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
AuthorizedOfficialTelephone: | 4146496797 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 32759500 | 05 | WI |   | MEDICAID | 32852800 | 05 | WI |   | MEDICAID | CD0491 | 01 | WI | MEDICARE RAILROAD | OTHER | 32676700 | 05 | WI |   | MEDICAID | CN5106 | 01 | WI | MEDICARE RAILROAD | OTHER | CE8880 | 01 | WI | MEDICARE RAILROAD | OTHER | CI9485 | 01 | WI | MEDICARE RAILROAD | OTHER |