Provider Demographics
NPI:1184866253
Name:MED GROUP TRANSPORTATION LLC
Entity Type:Organization
Organization Name:MED GROUP TRANSPORTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:MEKVABISHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-755-0500
Mailing Address - Street 1:11412 N PORT WASHINGTON RD STE 215
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3450
Mailing Address - Country:US
Mailing Address - Phone:414-755-0500
Mailing Address - Fax:414-755-1763
Practice Address - Street 1:11412 N PORT WASHINGTON RD STE 215
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3450
Practice Address - Country:US
Practice Address - Phone:414-755-0500
Practice Address - Fax:414-755-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI376ZYF343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100002648Medicaid