MEDICARE: HOLTON STREET CLINIC, 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	251V00000X	Voluntary or Charitable Agency	3476800	WI

General Provider Information

NPI Number	:	1184882284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLTON STREET CLINIC, INC.

Provider Business Mailing Address
First Line	:	3251 N HOLTON ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2126
Country	:	US
Telephone Number	:	414-264-8800
Fax Number	:	414-264-7766

Provider Business Practice Location Address
First Line	:	3251 N HOLTON ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2126
Country	:	US
Telephone Number	:	414-264-8800
Fax Number	:	414-264-7766

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SHEILA JHANSALE
Credential	:	M.D.
Telephone Number	:	414-264-8800

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	09/16/2015

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