Basic Information
Provider Information | |||||||||
NPI: | 1164801262 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FROEDTERT PHYSICIAN PARTNERS INC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | N74W12501 LEATHERWOOD CT | ||||||||
Address2: |   | ||||||||
City: | MENOMONEE FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 530514490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4147770417 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | W168N11237 WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | WI | ||||||||
PostalCode: | 530223239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622535060 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2015 | ||||||||
LastUpdateDate: | 09/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MATHEWS | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4148053750 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 09/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   | WI | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.