Provider Demographics
NPI:1063830479
Name:FROEDTERT &THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS, INC.
Entity Type:Organization
Organization Name:FROEDTERT &THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS, INC.
Other - Org Name:FROEDTERT PHYSICIAN PARTNERS, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:ABBAS
Authorized Official - Last Name:GHAFERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-660-4939
Mailing Address - Street 1:N74 W12501 LEATHERWOOD CT
Mailing Address - Street 2:400 WOODLAND PRIME
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W129N7055 NORTHFIELD DRIVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-0538
Practice Address - Country:US
Practice Address - Phone:262-253-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
6521570014OtherMEDICARE DME CONTRACTOR