Provider Demographics
NPI:1700022936
Name:MOLINA HEALTHCARE OF WISCONSIN
Entity Type:Organization
Organization Name:MOLINA HEALTHCARE OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PLAN PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-847-1765
Mailing Address - Street 1:2400 S 102ND ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2132
Mailing Address - Country:US
Mailing Address - Phone:414-847-1766
Mailing Address - Fax:414-847-1778
Practice Address - Street 1:2400 S 102ND ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2132
Practice Address - Country:US
Practice Address - Phone:414-847-1766
Practice Address - Fax:414-847-1778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOLINA HEALTHCARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-17
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18011302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI69004600Medicaid