Provider Demographics
NPI:1285716308
Name:RAVENSWOOD CLINIC INC
Entity type:Organization
Organization Name:RAVENSWOOD CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:WERTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS
Authorized Official - Phone:414-224-0492
Mailing Address - Street 1:2266 N PROSPECT AVE
Mailing Address - Street 2:SUITE 326
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6306
Mailing Address - Country:US
Mailing Address - Phone:414-224-0492
Mailing Address - Fax:414-224-8112
Practice Address - Street 1:2266 N PROSPECT AVE
Practice Address - Street 2:SUITE 608
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6306
Practice Address - Country:US
Practice Address - Phone:414-224-0492
Practice Address - Fax:414-224-8112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2118261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIL12215600Medicaid
WI000073725Medicare ID - Type Unspecified