Provider Demographics
NPI:1639115090
Name:TANEJA, AMIT (MD)
Entity Type:Individual
Prefix:
First Name:AMIT
Middle Name:
Last Name:TANEJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:PULMONARY AND CRITICAL CARE MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-7040
Mailing Address - Fax:414-955-6211
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:PULMONARY AND CRITICAL CARE MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-7040
Practice Address - Fax:414-955-6211
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109523207R00000X
WI51772207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36109523Medicaid
WI1639115090Medicaid
WI1639115090Medicaid
WI736012122Medicare PIN
IL36109523Medicaid
ILK30839Medicare PIN