Provider Demographics
NPI:1578510798
Name:WISCONSIN AVENUE MEDICAL CLINIC,S.C.
Entity Type:Organization
Organization Name:WISCONSIN AVENUE MEDICAL CLINIC,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRAMHADEVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-352-2187
Mailing Address - Street 1:1020 E AMBER LN
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-3349
Mailing Address - Country:US
Mailing Address - Phone:414-764-2024
Mailing Address - Fax:
Practice Address - Street 1:3505 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3847
Practice Address - Country:US
Practice Address - Phone:414-344-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty