Basic Information
| Provider Information | |||||||||
| NPI: | 1942689047 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC | ||||||||
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| OtherOrganizationName: | FROEDTERT PHYSICIAN PARTNERS INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | N74W12507 LEATHERWOOD CT | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147770417 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 LONE OAK LN | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530272600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626701800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATHEWS | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4148053750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | WI | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.