Provider Demographics
NPI:1730853870
Name:ERC WISCONSIN, LLC
Entity type:Organization
Organization Name:ERC WISCONSIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING & CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-214-9321
Mailing Address - Street 1:7351 E LOWRY BLVD SUITE #200
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-1428
Mailing Address - Country:US
Mailing Address - Phone:414-727-4455
Mailing Address - Fax:
Practice Address - Street 1:2500 N MAYFAIR RD STE 600
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1428
Practice Address - Country:US
Practice Address - Phone:414-727-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No283Q00000XHospitalsPsychiatric Hospital