Provider Demographics
NPI:1215140827
Name:MEDVED ENT, SC
Entity type:Organization
Organization Name:MEDVED ENT, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:M
Authorized Official - Last Name:MEDVED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-529-9330
Mailing Address - Street 1:9200 W LOOMIS RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8887
Mailing Address - Country:US
Mailing Address - Phone:414-529-9330
Mailing Address - Fax:414-529-9331
Practice Address - Street 1:9200 W LOOMIS RD
Practice Address - Street 2:SUITE 206
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8887
Practice Address - Country:US
Practice Address - Phone:414-529-9330
Practice Address - Fax:414-529-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24579174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30756000Medicaid
WI000001575Medicare ID - Type Unspecified
WI30756000Medicaid