Provider Demographics
NPI:1275767485
Name:MHS CONVENIENT CARE CLINIC
Entity Type:Organization
Organization Name:MHS CONVENIENT CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:FRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-372-8080
Mailing Address - Street 1:2555 N MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2709
Mailing Address - Country:US
Mailing Address - Phone:414-372-8080
Mailing Address - Fax:414-372-7425
Practice Address - Street 1:4061 N 54TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1377
Practice Address - Country:US
Practice Address - Phone:414-372-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILWAUKEE HEALTH SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-04
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6282-800363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33724600Medicaid
WI43086700Medicaid
WI521829OtherMEDICARE UGS#
WI1518005818Medicaid
WI32958200Medicaid
WI42183000Medicaid
WI44066400Medicaid
WI33782900Medicaid
WI32831100Medicaid
WI521804OtherMEDICARE USG#
WI33780500Medicaid
WI1518005818Medicaid