Provider Demographics
NPI:1558807131
Name:MIDWEST NEPHROLOGY ASSOCIATES, SC
Entity Type:Organization
Organization Name:MIDWEST NEPHROLOGY ASSOCIATES, SC
Other - Org Name:MNA SURGERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-762-2020
Mailing Address - Street 1:335 MAHN COURT
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-2155
Mailing Address - Country:US
Mailing Address - Phone:414-762-2020
Mailing Address - Fax:414-762-2024
Practice Address - Street 1:7797 W APPLETON AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222
Practice Address - Country:US
Practice Address - Phone:414-393-2690
Practice Address - Fax:414-393-2693
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST NEPHROLOGY ASSOCIATES, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32796300Medicaid
WI32796300Medicaid