Healthcare Provider Details

I. General information

NPI: 1952569816
Provider Name (Legal Business Name): GREATER MILWAUKEE CRITICAL CARE AND PULMONARY ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 S 16TH ST 2015
MILWAUKEE WI
53215-4537
US

IV. Provider business mailing address

PO BOX 070520
MILWAUKEE WI
53207-0520
US

V. Phone/Fax

Practice location:
  • Phone: 414-840-0198
  • Fax:
Mailing address:
  • Phone: 414-840-0198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number45393
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number39828
License Number StateWI

VIII. Authorized Official

Name: DR. RAKESH WAGHRAY
Title or Position: OFFICER
Credential: MD
Phone: 414-840-0198