Provider Demographics
NPI:1023064086
Name:GERALD L. IGNACE INDIAN HEALTH CENTER, INC.
Entity type:Organization
Organization Name:GERALD L. IGNACE INDIAN HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:IGNACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:414-383-9526
Mailing Address - Street 1:930 W HISTORIC MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3533
Mailing Address - Country:US
Mailing Address - Phone:414-383-9526
Mailing Address - Fax:414-389-3881
Practice Address - Street 1:930 W HISTORIC MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3533
Practice Address - Country:US
Practice Address - Phone:414-383-9526
Practice Address - Fax:414-649-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32957100Medicaid
WI093488131OtherCHAMPUS
WI772262Medicare UPIN
WI093488131OtherCHAMPUS
WIE39494Medicare UPIN
WI32957100Medicaid
000073805Medicare PIN