Provider Demographics
NPI:1184648453
Name:GLENDALE ANESTHESIA ASSOCIATES
Entity Type:Organization
Organization Name:GLENDALE ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:WENNIGER
Authorized Official - Last Name:NIEDFELDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-365-3210
Mailing Address - Street 1:4555 WEST SCHROEDER DRIVE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:414-365-3225
Practice Address - Street 1:575 WEST RIVER WOODS PARKWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-961-6700
Practice Address - Fax:414-961-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32810600Medicaid
WI32810600Medicaid