Basic Information
| Provider Information | |||||||||
| NPI: | 1013450006 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FROEDTERT HOSPITAL RAYUS RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | N74W12501 LEATHERWOOD CT | ||||||||
| Address2: | 400 WOODLAND PRIME | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147770417 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | W129N7055 NORTHFIELD DR | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530510538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622515305 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2016 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONLEY | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, FROEDTERT HOSPITAL | ||||||||
| AuthorizedOfficialTelephone: | 4148052915 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 279,232 | WI | N | Hospitals | General Acute Care Hospital | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.