Provider Demographics
NPI:1760648513
Name:INDEPENDENT CARE HEALTH PLAN
Entity Type:Organization
Organization Name:INDEPENDENT CARE HEALTH PLAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEROMINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-223-4847
Mailing Address - Street 1:1555 N RIVERCENTER DR
Mailing Address - Street 2:SUITE 202A
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3981
Mailing Address - Country:US
Mailing Address - Phone:414-223-4847
Mailing Address - Fax:414-231-1092
Practice Address - Street 1:1555 N RIVERCENTER DR
Practice Address - Street 2:SUITE 202A
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3981
Practice Address - Country:US
Practice Address - Phone:414-223-4847
Practice Address - Fax:414-231-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization