=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952199275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDOC WISCONSIN TELEHEALTH SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2025
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 N JEFFERSON ST STE 408
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53202-3875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-378-9549
-----------------------------------------------------
Fax | 877-712-5707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4635 SOUTHWEST FWY STE 525
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77027-7157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-378-9549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MBA
-----------------------------------------------------
Name | NATALYA MELNIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-378-9549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------