MEDICARE: BLUE RIBBON HEALTHCARE 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	302R00000X	Health Maintenance Organization	1154576	WI

General Provider Information

NPI Number	:	1528423290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIBBON HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 510442
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53203
Country	:	US
Telephone Number	:	414-643-4987
Fax Number	:	414-643-5046

Provider Business Practice Location Address
First Line	:	1743 SOUTH1ST STREET
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204
Country	:	US
Telephone Number	:	414-643-4987
Fax Number	:	414-643-5046

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	MR. MIKE WHITE II
Credential	:	BS
Telephone Number	:	414-643-4987

Provider Enumeration Date	:	12/23/2015
Last Update Date	:	12/23/2015

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