Provider Demographics
NPI:1225150709
Name:UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
Other - Org Name:RETINA CONSULTANTS, UWMF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-399-1141
Mailing Address - Street 1:345 EXECUTIVE PKWY
Mailing Address - Street 2:SUITE M4
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5340
Mailing Address - Country:US
Mailing Address - Phone:815-399-1141
Mailing Address - Fax:815-397-7816
Practice Address - Street 1:345 EXECUTIVE PKWY
Practice Address - Street 2:SUITE M4
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5340
Practice Address - Country:US
Practice Address - Phone:815-399-1141
Practice Address - Fax:815-397-7816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10121807OtherBCBS OF IL GROUP NUMBER
IL10121807OtherBCBS OF IL GROUP NUMBER