Provider Demographics
NPI:1073549739
Name:WISCONSIN HEART CENTER S C
Entity Type:Organization
Organization Name:WISCONSIN HEART CENTER S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-481-8400
Mailing Address - Street 1:1233 N MAYFAIR RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3255
Mailing Address - Country:US
Mailing Address - Phone:414-774-6300
Mailing Address - Fax:
Practice Address - Street 1:1233 N MAYFAIR RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3255
Practice Address - Country:US
Practice Address - Phone:414-774-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32824100Medicaid
WI32824100Medicaid