Provider Demographics
NPI:1841426798
Name:WISCONSIN VASCULAR ACCESS AND NEPHROLOGY
Entity Type:Organization
Organization Name:WISCONSIN VASCULAR ACCESS AND NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-427-7820
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-0932
Mailing Address - Country:US
Mailing Address - Phone:414-427-7820
Mailing Address - Fax:414-427-7824
Practice Address - Street 1:1962 N PROSPECT AVE # 310
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1414
Practice Address - Country:US
Practice Address - Phone:414-803-2721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38379-020207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32303500Medicaid
WIWI1296Medicare Oscar/Certification
WID92110Medicare UPIN
WI32303500Medicaid