Provider Demographics
NPI:1417919275
Name:PADDOCK LAKE FAMILY PRACTICE, SC
Entity Type:Organization
Organization Name:PADDOCK LAKE FAMILY PRACTICE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-843-2394
Mailing Address - Street 1:7137 236TH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-9664
Mailing Address - Country:US
Mailing Address - Phone:262-843-4422
Mailing Address - Fax:262-843-1166
Practice Address - Street 1:7137 236TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-9664
Practice Address - Country:US
Practice Address - Phone:262-843-4422
Practice Address - Fax:262-843-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD7478OtherRAIL ROAD MEDICARE
WI21291800Medicaid
WI21291800Medicaid
WI=========011OtherBC/BS CLINIC