Provider Demographics
NPI:1346864394
Name:MTG CAPITAL OF WISCONSIN LLC
Entity Type:Organization
Organization Name:MTG CAPITAL OF WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF CLIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:GESKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-601-8395
Mailing Address - Street 1:13277 ILLINOIS ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8601
Mailing Address - Country:US
Mailing Address - Phone:317-601-8395
Mailing Address - Fax:317-203-0707
Practice Address - Street 1:13277 ILLINOIS ST STE 100
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8601
Practice Address - Country:US
Practice Address - Phone:317-601-8395
Practice Address - Fax:317-203-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health