Basic Information
| Provider Information | |||||||||
| NPI: | 1952841868 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEMORIAL HOSPITAL OF MENOMONEE FALLS, INC | ||||||||
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| OtherOrganizationName: | COMMUNITY MEMORIAL HOSPITAL FAMILY MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | N74 W12501 LEATHERWOOD CT | ||||||||
| Address2: | WOODLAND PRIME 400, PATIENT FINANCIAL SERVICES | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147772041 | ||||||||
| FaxNumber: | 4147770096 | ||||||||
| Practice Location | |||||||||
| Address1: | W180N8000 TOWN HALL RD | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625323700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2017 | ||||||||
| LastUpdateDate: | 05/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | VAN DE KREEKE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4147770968 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY MEMORIAL HOSPITAL OF MENOMONEE FALLS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11011200 | 05 | WI | MEDICAID |