Provider Demographics
NPI:1023224458
Name:JITENDRA K BARUAH MD SC
Entity Type:Organization
Organization Name:JITENDRA K BARUAH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JITENDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BARUAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-384-5581
Mailing Address - Street 1:19175 STILL POINT TRL
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4808
Mailing Address - Country:US
Mailing Address - Phone:414-384-5581
Mailing Address - Fax:414-384-5644
Practice Address - Street 1:3201 S 16TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4537
Practice Address - Country:US
Practice Address - Phone:414-384-5581
Practice Address - Fax:414-384-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30288000Medicaid
WI30288000Medicaid