MEDICARE: PADRE PIO PEDIATRICS 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	43966-020	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	:	1831461326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PADRE PIO PEDIATRICS LLC

Provider Business Mailing Address
First Line	:	929 W MITCHELL ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-3534
Country	:	US
Telephone Number	:	414-384-6612
Fax Number	:	414-384-6613

Provider Business Practice Location Address
First Line	:	929 W MITCHELL ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-3534
Country	:	US
Telephone Number	:	262-945-4170
Fax Number	:	800-208-2413

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SYED N HASNAIN
Credential	:	M.D.
Telephone Number	:	414-873-9800

Provider Enumeration Date	:	01/31/2012
Last Update Date	:	01/31/2012

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