Basic Information
| Provider Information | |||||||||
| NPI: | 1396023198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT MIDWEST FOOT AND ANKLE CENTERS, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8153 S 27TH ST | ||||||||
| Address2: | 400 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531329549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147610981 | ||||||||
| FaxNumber: | 4147611614 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 W BROWN DEER RD | ||||||||
| Address2: | |||||||||
| City: | BAYSIDE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532172319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147610981 | ||||||||
| FaxNumber: | 4147611614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2011 | ||||||||
| LastUpdateDate: | 01/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | MATTEUCCI | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DONALD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4147611613 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 43237400 | 05 | WI | MEDICAID |