Basic Information
| Provider Information | |||||||||
| NPI: | 1821031873 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WETLAND EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7360 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191017360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004447009 | ||||||||
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| Practice Location | |||||||||
| Address1: | 855 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OCONTO FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541541241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207463444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXEC VICE PRES, EPP | ||||||||
| AuthorizedOfficialTelephone: | 8003622731 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32884700 | 05 | WI | MEDICAID |