Provider Demographics
NPI:1548337603
Name:MEQUON JEWISH CAMPUS, INC
Entity type:Organization
Organization Name:MEQUON JEWISH CAMPUS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-478-1501
Mailing Address - Street 1:1414 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3018
Mailing Address - Country:US
Mailing Address - Phone:262-478-1500
Mailing Address - Fax:262-478-0355
Practice Address - Street 1:10995 N MARKET ST
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-4952
Practice Address - Country:US
Practice Address - Phone:262-478-1500
Practice Address - Fax:262-478-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5017314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525682Medicare ID - Type Unspecified