Provider Demographics
NPI:1043228505
Name:THE REDI CLINIC OF WAUWATOSA, SC
Entity Type:Organization
Organization Name:THE REDI CLINIC OF WAUWATOSA, SC
Other - Org Name:PATHWAY CLINIC, SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELTZIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-727-4455
Mailing Address - Street 1:2500 N. MAYFAIR RD, STE 600
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-727-4455
Mailing Address - Fax:414-727-4690
Practice Address - Street 1:2500 N. MAYFAIR RD, STE 600
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-727-4455
Practice Address - Fax:414-727-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1729101YA0400X, 101YM0800X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043228505Medicaid
WI42127100Medicaid
WI84793OtherMEDICARE GROUP NUMBER
WI44485Medicare PIN