Provider Demographics
NPI:1871665091
Name:WISCONSIN REHABILITATION MEDICINE PROFESSIONALS, SC
Entity Type:Organization
Organization Name:WISCONSIN REHABILITATION MEDICINE PROFESSIONALS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRIDHAR
Authorized Official - Middle Name:V
Authorized Official - Last Name:VASUDEVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-285-3888
Mailing Address - Street 1:PO BOX 1790
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53008-1790
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5200 LAKEVIEW RIDGE RD
Practice Address - Street 2:
Practice Address - City:BELGIUM
Practice Address - State:WI
Practice Address - Zip Code:53004-9423
Practice Address - Country:US
Practice Address - Phone:262-285-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000068108Medicare PIN
WI000002096Medicare PIN
WI000040225Medicare PIN