Provider Demographics
NPI:1831371442
Name:RAM K MITTAL MD SC
Entity type:Organization
Organization Name:RAM K MITTAL MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:MITTAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-762-3910
Mailing Address - Street 1:902 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-2118
Mailing Address - Country:US
Mailing Address - Phone:414-762-3910
Mailing Address - Fax:414-762-9694
Practice Address - Street 1:902 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-2118
Practice Address - Country:US
Practice Address - Phone:414-762-3910
Practice Address - Fax:414-762-9694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20701208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30152400Medicaid
020020620OtherRR MEDICARE
WI30152400Medicaid
WI000073556Medicare PIN