Provider Demographics
NPI:1982621827
Name:WISCONSIN MEDICAL SUPPLIES INC
Entity Type:Organization
Organization Name:WISCONSIN MEDICAL SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YASER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOHAMMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-631-0100
Mailing Address - Street 1:5200 WASHINGTON AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4238
Mailing Address - Country:US
Mailing Address - Phone:262-631-0100
Mailing Address - Fax:262-631-0200
Practice Address - Street 1:5200 WASHINGTON AVE
Practice Address - Street 2:STE 105
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4238
Practice Address - Country:US
Practice Address - Phone:262-631-0100
Practice Address - Fax:262-631-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41756900Medicaid
WI41756900Medicaid