MEDICARE: WESTSIDE HEALTHCARE ASSOCIATION INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	4109	WI
2	363A00000X	Physician Assistant	2023	WI
3	207Q00000X	Family Medicine Physician	49433	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245490127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTSIDE HEALTHCARE ASSOCIATION INC

Provider Business Mailing Address
First Line	:	3522 W LISBON AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1953
Country	:	US
Telephone Number	:	414-935-8000
Fax Number	:	414-755-0058

Provider Business Practice Location Address
First Line	:	3522 W LISBON AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1953
Country	:	US
Telephone Number	:	414-935-8000
Fax Number	:	414-755-0058

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MS. TANGELA M POOLE
Credential	:
Telephone Number	:	414-934-7582

Provider Enumeration Date	:	06/13/2008
Last Update Date	:	06/13/2008

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Directions to “WESTSIDE HEALTHCARE ASSOCIATION INC ” Practice Location

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