Provider Demographics
NPI:1003831132
Name:FROEDTERT SOUTH, INC.
Entity Type:Organization
Organization Name:FROEDTERT SOUTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:262-577-8113
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-656-2011
Mailing Address - Fax:
Practice Address - Street 1:9555 76TH ST
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1984
Practice Address - Country:US
Practice Address - Phone:262-577-8000
Practice Address - Fax:262-653-5852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52-2335261QE0700X
WI52-0021282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11007800Medicaid
WI11007800Medicaid
WI52-0021Medicare ID - Type Unspecified