Provider Demographics
NPI:1043242811
Name:FAMILY DOCTORS, SC
Entity Type:Organization
Organization Name:FAMILY DOCTORS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:K
Authorized Official - Last Name:MISRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-643-7448
Mailing Address - Street 1:3267 S 16TH ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4500
Mailing Address - Country:US
Mailing Address - Phone:414-643-7448
Mailing Address - Fax:414-643-7482
Practice Address - Street 1:3267 S 16TH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4500
Practice Address - Country:US
Practice Address - Phone:414-643-7448
Practice Address - Fax:414-643-7482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21251200Medicaid
CH8008OtherRR MEDICARE
CH8008OtherRR MEDICARE