Provider Demographics
NPI:1104222330
Name:PREMIER CARDIOVASCULAR INSTITUTE OF WISCONSIN LLC
Entity Type:Organization
Organization Name:PREMIER CARDIOVASCULAR INSTITUTE OF WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OBRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KOKANOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-750-8202
Mailing Address - Street 1:2500 W LAYTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5420
Mailing Address - Country:US
Mailing Address - Phone:406-750-8202
Mailing Address - Fax:
Practice Address - Street 1:1309 S 54TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3404
Practice Address - Country:US
Practice Address - Phone:406-750-8202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51767261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI127766Medicaid