Provider Demographics
NPI:1104711605
Name:SOLIDARITUS HEALTH WISCONSIN SC
Entity type:Organization
Organization Name:SOLIDARITUS HEALTH WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:JAQUETTE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-461-0463
Mailing Address - Street 1:1025 CONNECTICUT AVE NW STE 907
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-5434
Mailing Address - Country:US
Mailing Address - Phone:888-491-2951
Mailing Address - Fax:
Practice Address - Street 1:915 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3921
Practice Address - Country:US
Practice Address - Phone:414-348-8970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOLIDARITUS HEALTH WISCONSIN SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty