Basic Information
| Provider Information | |||||||||
| NPI: | 1316101595 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREAT LAKES FOOT & ANKLE OF GREATER MILWAUKEE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8153 S 27TH ST | ||||||||
| Address2: | 400 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531329549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147610981 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8153 S 27TH ST | ||||||||
| Address2: | 400 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531329549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147610981 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 12/27/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATTEUCCI | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4147610981 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.P.M. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Podiatric |
ID Information
| ID | Type | State | Issuer | Description | 1316101595 | 05 | WI | MEDICAID | WI1772 | 01 | WI | PTAN | OTHER |