Provider Demographics
NPI:1255324752
Name:WESTERN WISCONSIN MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:WESTERN WISCONSIN MEDICAL ASSOCIATES
Other - Org Name:VIBRANT HEALTH FAMILY CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KERITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:LIJEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-425-6701
Mailing Address - Street 1:1687 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-1571
Mailing Address - Country:US
Mailing Address - Phone:715-425-6701
Mailing Address - Fax:715-426-3994
Practice Address - Street 1:1687 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-1571
Practice Address - Country:US
Practice Address - Phone:715-425-6701
Practice Address - Fax:715-426-3994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32748700Medicaid
WI3878850001Medicare NSC
WI32748700Medicaid