Healthcare Provider Details

I. General information

NPI: 1366959447
Provider Name (Legal Business Name): INDEPENDENT PHYSICIANS OF WISCONSIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
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: 414-875-6786
Mailing address:
  • Phone: 414-875-0505
  • Fax: 414-875-6786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

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