Provider Demographics
NPI:1386109429
Name:ADVOCATE AURORA HEALTHCARE
Entity type:Organization
Organization Name:ADVOCATE AURORA HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:IFEANYI
Authorized Official - Middle Name:
Authorized Official - Last Name:OSUDE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:815-404-9290
Mailing Address - Street 1:815 LINCOLN DR W APT 7
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4754
Mailing Address - Country:US
Mailing Address - Phone:815-404-9290
Mailing Address - Fax:
Practice Address - Street 1:3003 W GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2042
Practice Address - Country:US
Practice Address - Phone:414-352-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-03
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14480Medicaid