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General NPI Number Information
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NPI Number | 1376640342
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Entity Type | Organization
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Legal Business Name | MAGO MEDICAL INC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 573 W LINCOLN AVE
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City | MILWAUKEE
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State | WI
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Zip | 53207-1141
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Country | US
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Telephone | 414-385-9801
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Fax | 414-385-9803
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Provider Business Mailing Address
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Address Line | PO BOX 11430
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City | MILWAUKEE
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State | WI
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Zip | 53211-0430
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Country | US
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Telephone | 414-962-9070
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Fax | 414-962-9050
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. MICHAEL GLENN OLACIREGUI
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Credential | M.D.
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Telephone | 414-385-9801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 42851-020
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License Number State | WI
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