Healthcare Provider Details

I. General information

NPI: 1871975920
Provider Name (Legal Business Name): INDEPENDENT PHYSICIANS OF WISCONSIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5434 W CAPITOL DR STE 3
MILWAUKEE WI
53216-2298
US

IV. Provider business mailing address

5434 W CAPITOL DR STE 3
MILWAUKEE WI
53216-2298
US

V. Phone/Fax

Practice location:
  • Phone: 414-875-0505
  • Fax:
Mailing address:
  • Phone: 414-875-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMAD QASIM KHAN
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 414-875-0505