Provider Demographics
NPI:1003108515
Name:CLINICA PANAMERICANA LLC
Entity Type:Organization
Organization Name:CLINICA PANAMERICANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HUGO
Authorized Official - Middle Name:F
Authorized Official - Last Name:GOITIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-389-0166
Mailing Address - Street 1:1225 W HISTORIC MITCHELL ST
Mailing Address - Street 2:211
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3383
Mailing Address - Country:US
Mailing Address - Phone:414-389-0166
Mailing Address - Fax:414-643-1003
Practice Address - Street 1:1225 W HISTORIC MITCHELL ST
Practice Address - Street 2:211
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3383
Practice Address - Country:US
Practice Address - Phone:414-389-0166
Practice Address - Fax:414-643-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26560-20305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30639900Medicaid