Provider Demographics
NPI:1164700027
Name:TRINITY INTEGRATIVE FAMILY MEDICINE
Entity Type:Organization
Organization Name:TRINITY INTEGRATIVE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIE
Authorized Official - Middle Name:LOREE
Authorized Official - Last Name:KOCOUREK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-427-1577
Mailing Address - Street 1:S72W13575 WOODS RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-3707
Mailing Address - Country:US
Mailing Address - Phone:414-427-1577
Mailing Address - Fax:414-427-1577
Practice Address - Street 1:15350 W NATIONAL AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5158
Practice Address - Country:US
Practice Address - Phone:262-782-9541
Practice Address - Fax:262-782-6541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty