Provider Demographics
NPI:1326599945
Name:WISCONSIN MEDICAL GROUP
Entity Type:Organization
Organization Name:WISCONSIN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEHOE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:262-339-9797
Mailing Address - Street 1:14295 WOODMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2390
Mailing Address - Country:US
Mailing Address - Phone:262-339-9797
Mailing Address - Fax:
Practice Address - Street 1:8800 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2400
Practice Address - Country:US
Practice Address - Phone:262-339-9797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5440321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty