Provider Demographics
NPI:1245406982
Name:MEDICAL MANAGEMENT ASSOCIATES LLC
Entity Type:Organization
Organization Name:MEDICAL MANAGEMENT ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WESTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-384-9880
Mailing Address - Street 1:2727 W CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2956
Mailing Address - Country:US
Mailing Address - Phone:414-384-9880
Mailing Address - Fax:414-384-0134
Practice Address - Street 1:2727 W CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-2956
Practice Address - Country:US
Practice Address - Phone:414-384-9880
Practice Address - Fax:414-384-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32836600Medicaid