Basic Information
Provider Information | |||||||||
NPI: | 1952609844 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AURORA ADVANCED HEALTHCARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3003 W GOOD HOPE RD | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532092042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4143523100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1061 E COMMERCE BLVD | ||||||||
Address2: |   | ||||||||
City: | SLINGER | ||||||||
State: | WI | ||||||||
PostalCode: | 530869326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626442900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2011 | ||||||||
LastUpdateDate: | 05/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONROE | ||||||||
AuthorizedOfficialFirstName: | EUGENE | ||||||||
AuthorizedOfficialMiddleName: | W. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4143523100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   | WI | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 41570800 | 05 | WI |   | MEDICAID |