Healthcare Provider Details

I. General information

NPI: 1356892376
Provider Name (Legal Business Name): THE MEDICAL COLLEGE OF WISCONSIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11340 W THEODORE TRECKER WAY
WEST ALLIS WI
53214-1135
US

IV. Provider business mailing address

8701 W WATERTOWN PLANK RD MEDICAL EDUCATION BUILDING M1552
MILWAUKEE WI
53226-3548
US

V. Phone/Fax

Practice location:
  • Phone: 800-881-5101
  • Fax:
Mailing address:
  • Phone: 414-955-2859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number18653-40
License Number StateWI

VIII. Authorized Official

Name: KATHERINE NORA GHARIBIAN
Title or Position: ASSISTANT PROFESSOR
Credential: PHARM.D.
Phone: 414-955-2859