Provider Demographics
NPI:1205090438
Name:MEDA CARE VANS OF WAUKESHA
Entity type:Organization
Organization Name:MEDA CARE VANS OF WAUKESHA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:V
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-264-2000
Mailing Address - Street 1:N15W24817 BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-4620
Mailing Address - Country:US
Mailing Address - Phone:262-650-1000
Mailing Address - Fax:262-650-1029
Practice Address - Street 1:N15W24817 BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-4620
Practice Address - Country:US
Practice Address - Phone:262-650-1000
Practice Address - Fax:262-650-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41459700Medicaid