Provider Demographics
NPI:1164637492
Name:ELKHORN FAMILY CLINIC
Entity Type:Organization
Organization Name:ELKHORN FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:SYED
Authorized Official - Last Name:MUZAFFAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-743-1122
Mailing Address - Street 1:100 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1732
Mailing Address - Country:US
Mailing Address - Phone:262-743-1122
Mailing Address - Fax:262-743-1582
Practice Address - Street 1:100 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1732
Practice Address - Country:US
Practice Address - Phone:262-743-1122
Practice Address - Fax:262-743-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
WI43819-020305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34151600Medicaid
WI34151600Medicaid
WIH52036Medicare UPIN