Basic Information
| Provider Information | |||||||||
| NPI: | 1124099445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOWNE CENTRE MEDICAL, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 19035 W CAPITOL DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530452706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627541421 | ||||||||
| FaxNumber: | 2627543760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 01/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | HORNER-IBLER | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2627541421 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 21296100 | 05 | WI | MEDICAID |