Provider Demographics
NPI:1194216416
Name:ST GEORGE CLINICS, LLC
Entity Type:Organization
Organization Name:ST GEORGE CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT NURSE PRACTIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TATJANA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVANOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:262-923-3777
Mailing Address - Street 1:308 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-4306
Mailing Address - Country:US
Mailing Address - Phone:262-923-3777
Mailing Address - Fax:
Practice Address - Street 1:308 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-4306
Practice Address - Country:US
Practice Address - Phone:262-923-3777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52D1037628261QM1300X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty