Basic Information
| Provider Information | |||||||||
| NPI: | 1255334173 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FROEDTERT HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | N74 W12501 LEATHERWOOD CT | ||||||||
| Address2: | WOODLAND PRIME 400, PFS, ATTN: T. LEMMERMANN | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147770417 | ||||||||
| FaxNumber: | 4147770096 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148053000 | ||||||||
| FaxNumber: | 4148057790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONLEY | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4148052915 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 232; 279 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 092365600 | 05 | FL | MEDICAID | 100036370A | 05 | IN | MEDICAID | 121634105 | 05 | AK | MEDICAID | 2277487 | 05 | OH | MEDICAID | 923550700 | 05 | MN | MEDICAID | 0939538 | 05 | IA | MEDICAID | 9000355 | 01 | WI | TOUCHPOINT | OTHER | 11000400 | 05 | WI | MEDICAID | 137793700 | 01 | WI | US DEPT OF LABOR | OTHER | 0095078 | 05 | MS | MEDICAID | 304656043 | 05 | MI | MEDICAID | 404656061 | 05 | MI | MEDICAID | 88601544 | 05 | CO | MEDICAID | 501166 | 01 | WI | DEAN HEALTH PLAN | OTHER | 01869896 | 05 | NY | MEDICAID | 5000021 | 01 | WI | UNITED HEALTHCARE | OTHER | E61000134 | 05 | NV | MEDICAID |