Basic Information
| Provider Information | |||||||||
| NPI: | 1962677310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VITOLA | ||||||||
| FirstName: | BERNADETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | PEDIATRIC GASTROENTEROLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663690 | ||||||||
| FaxNumber: | 4142663676 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | PEDIATRIC GASTROENTEROLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663690 | ||||||||
| FaxNumber: | 4142663676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 2006013758 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 208000000X | 57.007728 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080T0004X | 57.015938 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Transplant Hepatology | 2080P0206X | 54845 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1962677310 | 05 | WI | MEDICAID |