Provider Demographics
NPI:1821028887
Name:MILWAUKEE HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:MILWAUKEE HEALTH SERVICES, INC.
Other - Org Name:MARTIN LUTHER KING HERITAGE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TITO
Authorized Official - Middle Name:L
Authorized Official - Last Name:IZARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-372-8080
Mailing Address - Street 1:2555 N MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2709
Mailing Address - Country:US
Mailing Address - Phone:414-267-3702
Mailing Address - Fax:414-372-1697
Practice Address - Street 1:2555 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-267-3702
Practice Address - Fax:414-562-8084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8681-423336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32958200Medicaid
WI36228200Medicaid
WI36228200Medicaid
WI521829Medicare Oscar/Certification