Provider Demographics
NPI:1407039548
Name:ENDOCRINE CLINIC OF KENOSHA , S.C.
Entity Type:Organization
Organization Name:ENDOCRINE CLINIC OF KENOSHA , S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAHUDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-842-0420
Mailing Address - Street 1:3535 30TH AVE
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1632
Mailing Address - Country:US
Mailing Address - Phone:262-842-0420
Mailing Address - Fax:262-842-0423
Practice Address - Street 1:3535 30TH AVE
Practice Address - Street 2:SUITE 101B
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1632
Practice Address - Country:US
Practice Address - Phone:262-842-0420
Practice Address - Fax:262-842-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45853020207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34438700Medicaid