Provider Demographics
NPI:1447248182
Name:MORELAND MEDICAL CENTER
Entity type:Organization
Organization Name:MORELAND MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ANCILLARY SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:STAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-452-8020
Mailing Address - Street 1:1111 DELAFIELD ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3417
Mailing Address - Country:US
Mailing Address - Phone:262-542-8020
Mailing Address - Fax:262-650-4398
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE 301
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-542-8020
Practice Address - Fax:262-650-4398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32908800Medicaid
WI32908800Medicaid