Provider Demographics
NPI:1346657442
Name:MILWAUKEE HEALTH SERVICES INC
Entity Type:Organization
Organization Name:MILWAUKEE HEALTH SERVICES INC
Other - Org Name:MARTIN LUTHER KING HERITAGE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TITO
Authorized Official - Middle Name:L
Authorized Official - Last Name:IZARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-267-2022
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:414-267-2022
Mailing Address - Fax:414-372-7420
Practice Address - Street 1:2555 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-267-2022
Practice Address - Fax:414-372-7420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI102001-30251B00000X
WI72014-30251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000002690OtherMEDICARE PTAN
WI521829Medicare Oscar/Certification
WI000002690OtherMEDICARE PTAN