Basic Information
| Provider Information | |||||||||
| NPI: | 1518092410 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIXTEENTH STREET COMMUNITY HEALTH CENTERS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1337 S CESAR E CHAVEZ DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532042712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146726220 | ||||||||
| FaxNumber: | 4146720191 | ||||||||
| Practice Location | |||||||||
| Address1: | 2906 S 20TH ST | ||||||||
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| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146721353 | ||||||||
| FaxNumber: | 4146724265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | MASCHEK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE AND STRATEGY | ||||||||
| AuthorizedOfficialTelephone: | 4148975156 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207T00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207V00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 213E00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 251B00000X | N | Agencies | Case Management | 363A00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 163W00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207Q00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 32958300 | 05 | WI | MEDICAID |