Provider Demographics
NPI:1194142356
Name:ELEOS MEDICAL GROUP
Entity type:Organization
Organization Name:ELEOS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMI
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:HAYES-MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-628-1004
Mailing Address - Street 1:4429 W FOND DU LAC AVE
Mailing Address - Street 2:SUITE #6
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3444
Mailing Address - Country:US
Mailing Address - Phone:414-459-3319
Mailing Address - Fax:414-444-8810
Practice Address - Street 1:4429 W FOND DU LAC AVE
Practice Address - Street 2:SUITE #6
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3444
Practice Address - Country:US
Practice Address - Phone:414-459-3319
Practice Address - Fax:414-444-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIH2528127056407343900000X
WI343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)