Healthcare Provider Details

I. General information

NPI: 1780724161
Provider Name (Legal Business Name): MILWAUKEE VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

IV. Provider business mailing address

1703 ESCADA
SAN ANTONIO TX
78258-4531
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone: 210-408-1004
  • Fax: 210-408-1004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number013746
License Number StateME

VIII. Authorized Official

Name: MR. GLEN GRIPPEN
Title or Position: RADIOLOGIST
Credential: MD
Phone: 414-384-2000