MEDICARE: THE PROVIDERS' GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	305S00000X	Point of Service

General Provider Information

NPI Number	:	1083918528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PROVIDERS' GROUP INC

Provider Business Mailing Address
First Line	:	3429 N 1ST ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-1528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3429 N 1ST ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-1528
Country	:	US
Telephone Number	:	414-732-8636
Fax Number	:

Authorized Official
Title or Position	:	EXCUTIVE DIRECTOR
Name	:	TATIA P JACKSON
Credential	:
Telephone Number	:	414-732-8636

Provider Enumeration Date	:	12/24/2010
Last Update Date	:	12/24/2010

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Directions to “THE PROVIDERS' GROUP INC ” Practice Location

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