Basic Information
| Provider Information | |||||||||
| NPI: | 1790242352 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | N74 W12501 LEATHERWOOD CT STE 103 | ||||||||
| Address2: | 400 WOODLAND PRIME | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147770417 | ||||||||
| FaxNumber: | 4147770096 | ||||||||
| Practice Location | |||||||||
| Address1: | 6255 N SANTA MONICA BLVD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532174353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149678350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2019 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | MATHEWS | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4148053750 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| 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.