Provider Demographics
NPI:1417300518
Name:PREVEA
Entity Type:Organization
Organization Name:PREVEA
Other - Org Name:PREVEA SHEBOYGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:
Authorized Official - Last Name:RAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-496-4700
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-3008
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1411 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3043
Practice Address - Country:US
Practice Address - Phone:920-803-1598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI149367261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care