Basic Information
| Provider Information | |||||||||
| NPI: | 1740218593 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AURORA MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | AURORA MEDICAL GROUP 20TH ST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2906 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143858800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2906 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143858800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAILET | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4146473047 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32762100 | 05 | WI | MEDICAID |