Provider Demographics
NPI:1487438875
Name:PRIVATE CLINIC.
Entity type:Organization
Organization Name:PRIVATE CLINIC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP, ADNP
Authorized Official - Phone:262-442-3912
Mailing Address - Street 1:10501 W RESEARCH DRIVE
Mailing Address - Street 2:SUITE G200
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:262-442-3912
Mailing Address - Fax:414-302-1040
Practice Address - Street 1:10501 W RESEARCH DRIVE
Practice Address - Street 2:SUITE G200
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:262-442-3912
Practice Address - Fax:414-302-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-24
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty