Provider Demographics
NPI:1396023198
Name:GREAT MIDWEST FOOT AND ANKLE CENTERS, S.C.
Entity Type:Organization
Organization Name:GREAT MIDWEST FOOT AND ANKLE CENTERS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:MATTEUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:414-761-1613
Mailing Address - Street 1:8153 S 27TH ST
Mailing Address - Street 2:400
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9549
Mailing Address - Country:US
Mailing Address - Phone:414-761-0981
Mailing Address - Fax:414-761-1614
Practice Address - Street 1:320 W BROWN DEER RD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:WI
Practice Address - Zip Code:53217-2319
Practice Address - Country:US
Practice Address - Phone:414-761-0981
Practice Address - Fax:414-761-1614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-27
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43237400Medicaid
WI6709590002Medicare NSC
WIV01175Medicare UPIN
WI6709590001Medicare NSC