Provider Demographics
NPI:1124098330
Name:VERSITI WISCONSIN, INC.
Entity type:Organization
Organization Name:VERSITI WISCONSIN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP CHIEF CORPORATE COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:BARTHOLOMEW
Authorized Official - Middle Name:
Authorized Official - Last Name:REUTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-937-6418
Mailing Address - Street 1:PO BOX 2178
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-2178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:638 N 18TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2121
Practice Address - Country:US
Practice Address - Phone:414-937-6160
Practice Address - Fax:414-933-7350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8375-423336S0011X
WI8375042333600000X
WI1719 FDA331L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes331L00000XSuppliersBlood Bank
No333600000XSuppliersPharmacy
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2110850OtherPK
WI32950300Medicaid
84481Medicare ID - Type Unspecified