CLEANSLATE MEDICAL GROUP OF WISCONSIN, SC (NPI# 1518404854) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1518404854 |
| Entity Type | Organization |
| Organization Name | CLEANSLATE MEDICAL GROUP OF WISCONSIN, SC |
| Practice Address |
377 W River Woods Pkwy Ste 201 Glendale WI 53212-1088 |
| Mailing Address |
15 Century Blvd Ste 307 Nashville TN 37214-3692 |
| Practice Telephone | 4133236880 |
| Mailing Telephone | 6154250220 |
| Enumeration Date | 2017-01-25 |
| Last Update Date | 2019-07-02 |
| Authorized Official Name | ROBERT HUTCHISON (CFO) |
| Authorized Official Telephone | 6154250220 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 207RA0401X |
Internal Medicine Specialization: Addiction Medicine |
Allopathic & Osteopathic Physicians |
| Street Address |
377 W RIVER WOODS PKWY STE 201 |
| City | GLENDALE |
| State | WI |
| Zip Code | 53212-1088 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1609481001 | Beth Leanna | Counselor | Benedict Center 1849 N Dr. Marin Luther King Dr., Suite 101, Milwaukee, WI 53212 | 2020-09-11 |
| 1326683749 | A.b.d.h. Counseling Services LLC | Clinic/Center | 518 E Concordia Avenue, Milwaukee, WI 53212 | 2019-11-08 |
| 1467095703 | Ifrah Hameed | Psychologist | 1849 N Doctor M.l.k. Jr Dr# 101, Milwaukee, WI 53212 | 2019-10-18 |
| 1386293330 | Rachel Mae Nelson Bagha | Student in an Organized Health Care Education/Training Program | 1849 N Doctor M.l.k. Jr Dr #101, Milwaukee, WI 53212 | 2019-09-11 |
| 1164085205 | Mary Sue Daase Bowen | Counselor | 2821 N 4th Street, Milwaukee, WI 53212 | 2019-04-15 |
| 1649733189 | Stacey King | Counselor | Rivershore Comprehensive Treatment Facility, 3703 N Richards St, Milwaukee Wi, Milwaukee, WI 53212 | 2019-04-11 |
| 1710447701 | Scott William Stauder | Student in an Organized Health Care Education/Training Program | 1121 E. North Ave., Milwaukee, WI 53212 | 2019-03-25 |
| 1821561168 | Lydia Ann Mendez | Counselor | 3703 N Richards St, Milwaukee, WI 53212 | 2019-01-09 |
| 1851863302 | Glen Victor Fleming | Counselor | 2821 North 4th Street Suite 210, Milwaukee, WI 53212 | 2018-12-21 |
| 1093285140 | Megan Marie Volp | Advanced Practice Midwife | 2555 N Doctor M.l.k. Jr Dr, Milwaukee, WI 53212 | 2018-12-03 |
| Find all providers in zip 53212 | ||||
| Taxonomy Code | 207RA0401X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Internal Medicine |
| Specialization | Addiction Medicine |
| An internist doctor of osteopathy that specializes in the treatment of addiction disorders. A doctor of osteopathy that is board eligible/certified by the American Osteopathic Board of Internal Medicine can obtain a Certificate of Added Qualifications in the field of Addiction Medicine. |
| Notes: Source: American Osteopathic Board of Internal Medicine, 2007. [7/1/2008: added definition, added source; 7/1/2011: modified source] - Additional Resources: http://www.osteopathic.org/certification |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1952955270 | New Day Medical LLC | Internal Medicine | 4655 N Pt Wash Rd, Glendale, WI 53212-1004 | 2019-07-25 |
| 1649428087 | Southern California Anesthesia Providers Scap | Internal Medicine | 1809 Verdugo Blvd Ste 140, Glendale, CA 91208-1402 | 2008-08-27 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1164596615 | Selahattin S. Kurter | Internal Medicine | 1661 N Water St, Suite 301, Milwaukee, WI 53202-2085 | 2006-11-17 |
| 1922627595 | Monarch Health | Internal Medicine | 521 E Washington Ave, Madison, WI 53703-2900 | 2020-04-13 |
| 1821624925 | Brittany Kay Gerovac | Internal Medicine | 521 E Washington Ave, Madison, WI 53703-2900 | 2020-03-20 |
| 1932695871 | Iris Health Clinic LLC | Internal Medicine | 403 N Grand Ave, Waukesha, WI 53186-4913 | 2018-07-03 |
| 1962911602 | Mareum Lucinda Connett | Internal Medicine | 3440 Oakwood Hills Pkwy, Eau Claire, WI 54701-7698 | 2017-09-26 |
| 1205263159 | Sullivan Medical Clinic, LLC | Internal Medicine | 6040 W Lisbon Ave, Suite 200, Milwaukee, WI 53210-2116 | 2013-10-07 |
| 1174890792 | Milind Mehta | Internal Medicine | 1220 Dewey Ave, Wauwatosa, WI 53213-2504 | 2011-11-28 |
| 1285824029 | Larry L Heller | Internal Medicine | 430 E Division St, Fond Du Lac, WI 54935-4560 | 2007-07-27 |
| 1851505416 | Michael S Goldstone | Internal Medicine | 2422 North Grandview Blvd, Waukesha, WI 53188 | 2007-05-10 |
| 1649484205 | Charles J Engel | Internal Medicine | 2422 North Grandview Blvd, Waukesha, WI 53188 | 2007-05-10 |
| Find all providers with the same taxonomy | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.