Provider Demographics
NPI:1114020633
Name:S T SY MD SC
Entity Type:Organization
Organization Name:S T SY MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:T
Authorized Official - Last Name:SY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-281-0400
Mailing Address - Street 1:4666 S 35TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221
Mailing Address - Country:US
Mailing Address - Phone:414-281-0400
Mailing Address - Fax:414-281-0402
Practice Address - Street 1:4666 S 35TH ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221
Practice Address - Country:US
Practice Address - Phone:414-281-0400
Practice Address - Fax:414-281-0402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19332020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI309677Medicaid
WI309677Medicaid