Provider Demographics
NPI:1417141227
Name:FAMILY FOOT CLINICS OF WISCONSIN SC
Entity Type:Organization
Organization Name:FAMILY FOOT CLINICS OF WISCONSIN SC
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-637-8806
Mailing Address - Street 1:3535 30TH AVE
Mailing Address - Street 2:203
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1632
Mailing Address - Country:US
Mailing Address - Phone:262-637-8806
Mailing Address - Fax:262-637-2868
Practice Address - Street 1:3535 30TH AVE
Practice Address - Street 2:#203
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1632
Practice Address - Country:US
Practice Address - Phone:262-657-6104
Practice Address - Fax:262-657-6194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43260300Medicaid
WI000046034Medicare UPIN
WI6066690001Medicare NSC
WI6066690002Medicare NSC
WI1417141227Medicare PIN
WI1871563601Medicare PIN