Provider Demographics
NPI:1376624320
Name:RI-LEE MEDICAL STAFFING, INC.
Entity Type:Organization
Organization Name:RI-LEE MEDICAL STAFFING, INC.
Other - Org Name:FOGARTY SURGICAL SERVICES AND FAMILY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-455-3124
Mailing Address - Street 1:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822-0144
Mailing Address - Country:US
Mailing Address - Phone:715-458-3124
Mailing Address - Fax:715-458-3125
Practice Address - Street 1:902 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:WI
Practice Address - Zip Code:54822-4910
Practice Address - Country:US
Practice Address - Phone:715-458-3124
Practice Address - Fax:715-458-3125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X
WI1845363A00000X
WI1673363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21288500Medicaid
WI000058055Medicare ID - Type UnspecifiedMEDICARE ID #