Basic Information
Provider Information | |||||||||
NPI: | 1518976919 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST BEND CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KEWASKUM CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1700 W PARADISE DR | ||||||||
Address2: |   | ||||||||
City: | WEST BEND | ||||||||
State: | WI | ||||||||
PostalCode: | 530959795 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2623343451 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1701 FOND DU LAC AVE | ||||||||
Address2: |   | ||||||||
City: | KEWASKUM | ||||||||
State: | WI | ||||||||
PostalCode: | 530409129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626264616 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 05/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLOMMEL | ||||||||
AuthorizedOfficialFirstName: | GREGORY | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2623343451 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 2085B0100X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 21251400 | 05 | WI |   | MEDICAID |