MEDICARE: MCMC PRIMARY CARE LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1568544633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCMC PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	5310 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2263
Country	:	US
Telephone Number	:	414-431-5004
Fax Number	:

Provider Business Practice Location Address
First Line	:	5310 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2263
Country	:	US
Telephone Number	:	414-431-5004
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. SYED GOUSE MOHIUDDIN
Credential	:	M.D
Telephone Number	:	414-431-5004

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	08/22/2020

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