Provider Demographics
NPI:1093973141
Name:COUNTY OF MILWAUKEE
Entity Type:Organization
Organization Name:COUNTY OF MILWAUKEE
Other - Org Name:MILWAUKEE COUNTY BEHAVIORAL HEALTH COMMUNITY SUPPORT PROGRAM SOUTHSIDE
Other - Org Type:Other Name
Authorized Official - Title/Position:ACTING HOSPITAL ADMISINTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-257-4823
Mailing Address - Street 1:9455 W WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3559
Mailing Address - Country:US
Mailing Address - Phone:414-257-6995
Mailing Address - Fax:
Practice Address - Street 1:9455 W WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3559
Practice Address - Country:US
Practice Address - Phone:414-257-6995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00812OtherMEDICARE ID
WI43420800Medicaid
WI43421000OtherMEDICAID PERFORMING PROVIDER