Provider Demographics
NPI:1437829975
Name:FROEDTERT MANITOWOC MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:FROEDTERT MANITOWOC MEDICAL GROUP, LLC
Other - Org Name:FROEDTERT NORTHEAST MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DEGERE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-320-2095
Mailing Address - Street 1:400 WOODLAND PRIME STE 103
Mailing Address - Street 2:N74 W12501 LEATHERWOOD COURT
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3712
Practice Address - Country:US
Practice Address - Phone:920-320-2436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-16
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty