MEDICARE: NOVA MEDICAL CENTER LLC

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	261QP2300X	Primary Care Clinic/Center	14421-020	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	:	1336310374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	3501 W GREENFIELD AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-1445
Country	:	US
Telephone Number	:	414-643-8815
Fax Number	:	414-643-8816

Provider Business Practice Location Address
First Line	:	3501 W GREENFIELD AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-1445
Country	:	US
Telephone Number	:	414-643-8815
Fax Number	:	414-643-8816

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. MAIYIA VANG
Credential	:
Telephone Number	:	414-643-8815

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	11/03/2016

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Directions to “NOVA MEDICAL CENTER LLC ” Practice Location

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