Provider Demographics
NPI:1861516957
Name:MARIA PORTELLOS PATTERSON, M.D., S.C.
Entity type:Organization
Organization Name:MARIA PORTELLOS PATTERSON, M.D., S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:P
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-641-8181
Mailing Address - Street 1:17000 W NORTH AVE STE 102E
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4423
Mailing Address - Country:US
Mailing Address - Phone:262-641-8181
Mailing Address - Fax:262-641-8188
Practice Address - Street 1:17000 W NORTH AVE STE 102E
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4423
Practice Address - Country:US
Practice Address - Phone:262-641-8181
Practice Address - Fax:262-641-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42757174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34034800Medicaid
WI01857Medicare ID - Type Unspecified
WI34034800Medicaid