Basic Information
Provider Information | |||||||||
NPI: | 1760829477 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FROEDTERT PHYSCIAN PARTNERS, INC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | WOODLAND PRIME 400 SUITE 103 | ||||||||
Address2: | N74 W12501 LEATHERWOOD COURT | ||||||||
City: | MENOMONEE FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 530514490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4147770417 | ||||||||
FaxNumber: | 4147770096 | ||||||||
Practice Location | |||||||||
Address1: | W227N16857 TILLIE LAKE CT | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | WI | ||||||||
PostalCode: | 530379000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2623656170 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2013 | ||||||||
LastUpdateDate: | 08/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MATHEWS | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4148053750 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 08/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.