NPIMap

Organization Active NPI

Milwaukee Health Services, Inc.

Doing business as MLK Heritage Health Center

  • Pharmacy
  • Milwaukee, WI
National Provider Identifier
1316980709
Registry record updated Apr 5, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
8681-42 Issued in WI
Legal business name
MILWAUKEE HEALTH SERVICES, INC.
Doing business as
MLK Heritage Health Center
Practice address
2555 N Martin Luther King Dr
Milwaukee, WI 53212-2709
Phone
(414) 267-2021
Fax
(414) 372-7420
NPI assigned
Jun 14, 2006
Last updated
Apr 5, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 5, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Tito L Izard, M.D.
Title
President Ceo
Phone
(414) 267-2021

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X
Pharmacy 333600000X 8681-42 WI Primary

Addresses

Primary practice location

2555 N Martin Luther King Dr
Milwaukee, WI 53212-2709

Mailing address

2555 N Martin Luther King Dr
Milwaukee, WI 53212-2709
Phone (414) 267-2021

Other identifiers 1

IdentifierTypeStateIssuer
32958200MedicaidWI

Other names 1

  • MLK Heritage Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040511000114 WI Part B Supplier - Clinic/Group Practice 7416946884 Receives reassigned benefits from 97 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Milwaukee, WI
O20060823000610 WI Part A Provider - Federally Qualified Health Center (FQHC) 7416946884 4 other NPIs on this enrollment
Practice locations: Milwaukee, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1316980709. Details of each certification follow.

Federally qualified health center certification: CCN 521829

Legal name
MILWAUKEE HEALTH SERVICES, INC.
Doing business as
MARTIN LUTHER KING HERITAGE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 12, 2006
Last certification
Oct 12, 2006
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Oct 27, 1989 in WI
Enrollment address
2555 N Martin Luther King Dr
Milwaukee, WI 53212-2709

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
52D0681642MLK Heritage Health Center2555 N Martin Luther King Dr, Milwaukee, WI 53212Provider-performed microscopyNov 26, 2027

National Provider Directory

National Provider Directory
Tax ID family
MHS Convenient Care Clinic9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Paula a Lucey Individual Corporate Director May 25, 2018
Tito L Izard Individual Corporate OfficerPresident and Ceo May 1, 2011
W-2 Managing EmployeePresident and Ceo May 1, 2019
Walter John Lanier Individual Corporate DirectorBoard Member May 25, 2018
Audrey Y Sellers Individual Corporate Director Nov 1, 2002
Antoinette Denise Herron Individual W-2 Managing Employee Jun 3, 2019
Karen Baker Individual Corporate Director Nov 1, 2002
Laurie Yake Individual Corporate OfficerCfo May 1, 2019
W-2 Managing EmployeeCfo May 1, 2019
Bridgett R Moss Individual Corporate OfficerBoard Member May 25, 2018
Jaddia Arnold Individual Corporate Director May 25, 2018
Gina L Green Harris Individual Corporate Director May 25, 2018

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150243200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1459814400000",
    "number": "1316980709",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2555 N MARTIN LUTHER KING DR",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532122709",
            "telephone_number": "414-267-2021",
            "fax_number": "414-372-7420"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2555 N MARTIN LUTHER KING DR",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532122709",
            "telephone_number": "414-267-2021",
            "fax_number": "414-372-7420"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MILWAUKEE HEALTH SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-14",
        "last_updated": "2016-04-05",
        "status": "A",
        "authorized_official_last_name": "IZARD",
        "authorized_official_first_name": "TITO",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT CEO",
        "authorized_official_telephone_number": "414-267-2021",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "WI",
            "license": "8681-42",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32958200",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MLK Heritage Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Milwaukee, WI

Sources for this page

Verify at the official NPI Registry.