Provider Demographics
NPI:1790092633
Name:MEDICAL COLLEGE OF WISCONSIN
Entity Type:Organization
Organization Name:MEDICAL COLLEGE OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCE PRACTICE NURSE PRESCRIBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GORDON-MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:APNP
Authorized Official - Phone:414-378-6212
Mailing Address - Street 1:2630 S 88TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2736
Mailing Address - Country:US
Mailing Address - Phone:414-378-6212
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4138-33282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital