Provider Demographics
NPI:1508856030
Name:SOUTH CENTER MEDICAL GROUP LTD
Entity Type:Organization
Organization Name:SOUTH CENTER MEDICAL GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SOUTH CENTER MEDICAL GRP
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-645-4240
Mailing Address - Street 1:3201 S 16TH ST
Mailing Address - Street 2:ROOM 1000
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4537
Mailing Address - Country:US
Mailing Address - Phone:414-645-4240
Mailing Address - Fax:414-645-8240
Practice Address - Street 1:3201 S 16TH ST
Practice Address - Street 2:ROOM 1000
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4537
Practice Address - Country:US
Practice Address - Phone:414-645-4240
Practice Address - Fax:414-645-8240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32734300Medicaid
WI32734300Medicaid