Healthcare Provider Details

I. General information

NPI: 1437319142
Provider Name (Legal Business Name): MEDICAL GENETICS INSTITUTE, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 W GOOD HOPE RD
GLENDALE WI
53209-2735
US

IV. Provider business mailing address

2311 W GOOD HOPE RD
GLENDALE WI
53209-2735
US

V. Phone/Fax

Practice location:
  • Phone: 414-228-0100
  • Fax: 414-228-8774
Mailing address:
  • Phone: 414-228-0100
  • Fax: 414-228-8774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number21932-020
License Number StateWI

VIII. Authorized Official

Name: MRS. MARIA M DE ELEJALDE
Title or Position: VICE PRESIDENT
Credential: M.S., R.N.
Phone: 414-228-0100