Basic Information
| Provider Information | |||||||||
| NPI: | 1699720086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE MEDICAL COLLEGE OF WISCONSIN, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 W INNOVATION DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149555006 | ||||||||
| FaxNumber: | 4149556079 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149555990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | KOPS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT, FINANCE/COO | ||||||||
| AuthorizedOfficialTelephone: | 4149558704 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 204E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 204F00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery | 207K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32739000 | 05 | WI | MEDICAID | 41170800 | 05 | WI | MEDICAID | 32730400 | 05 | WI | MEDICAID | 38381400 | 05 | WI | MEDICAID | 1699720086 | 05 | WI | MEDICAID |