Provider Demographics
NPI:1376640342
Name:MAGO MEDICAL INC
Entity type:Organization
Organization Name:MAGO MEDICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:OLACIREGUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-385-9801
Mailing Address - Street 1:PO BOX 11430
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-0430
Mailing Address - Country:US
Mailing Address - Phone:414-962-9070
Mailing Address - Fax:414-962-9050
Practice Address - Street 1:573 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-1141
Practice Address - Country:US
Practice Address - Phone:414-385-9801
Practice Address - Fax:414-385-9803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42851-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21285500Medicaid