Provider Demographics
NPI:1003909847
Name:WHITEFISH BAY FOOT & ANKLE CLINC, LLC
Entity Type:Organization
Organization Name:WHITEFISH BAY FOOT & ANKLE CLINC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DP
Authorized Official - Phone:414-967-1900
Mailing Address - Street 1:PO BOX 11430
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-0430
Mailing Address - Country:US
Mailing Address - Phone:414-962-9070
Mailing Address - Fax:414-962-9050
Practice Address - Street 1:155 E SILVER SPRING DR STE 205
Practice Address - Street 2:
Practice Address - City:WHITEFISH BAY
Practice Address - State:WI
Practice Address - Zip Code:53217-4704
Practice Address - Country:US
Practice Address - Phone:414-967-1900
Practice Address - Fax:414-967-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43266800Medicaid
WI43266800Medicaid
WIU80480Medicare UPIN