Provider Demographics
NPI:1336310374
Name:NOVA MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:NOVA MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAIYIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-643-8815
Mailing Address - Street 1:3501 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-1445
Mailing Address - Country:US
Mailing Address - Phone:414-643-8815
Mailing Address - Fax:414-643-8816
Practice Address - Street 1:3501 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-1445
Practice Address - Country:US
Practice Address - Phone:414-643-8815
Practice Address - Fax:414-643-8816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14421-020261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21282200Medicaid
WI000001296Medicare UPIN