Basic Information
| Provider Information | |||||||||
| NPI: | 1821517681 | ||||||||
| 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 | ||||||||
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| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532042712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148975511 | ||||||||
| FaxNumber: | 4143857552 | ||||||||
| Practice Location | |||||||||
| Address1: | 4570 S 27TH ST | ||||||||
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| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146721353 | ||||||||
| FaxNumber: | 4146724265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2017 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | MASCHEK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF 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 | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1821517681 | 05 | WI | MEDICAID |