MEDICARE: CH MASON HEALTH CLINIC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1508636358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CH MASON HEALTH CLINIC

Provider Business Mailing Address
First Line	:	3500 W MOTHER DANIELS WAY
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-5311
Country	:	US
Telephone Number	:	414-249-4613
Fax Number	:	414-249-4823

Provider Business Practice Location Address
First Line	:	4858 W. MOTHER DANIELS WAY
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209
Country	:	US
Telephone Number	:	414-249-4613
Fax Number	:	414-249-4823

Authorized Official
Title or Position	:	PROJECT MANAGER
Name	:	TANISHA COLLINS-JOHNSON
Credential	:
Telephone Number	:	414-249-4613

Provider Enumeration Date	:	01/03/2024
Last Update Date	:	01/03/2024

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