Basic Information
| Provider Information | |||||||||
| NPI: | 1689120982 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FROEDTERT PHYSICIANS PARTNERS, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | N74W12501 LEATHERWOOD CT, WOODLAND PRIME 400 | ||||||||
| Address2: | PATIENT FINANCIAL SERVICES | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147770417 | ||||||||
| FaxNumber: | 4147770096 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149555990 | ||||||||
| FaxNumber: | 4149556282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | VAN DE KREEKE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE & TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 4147770979 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS, INC | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.