Provider Demographics
NPI:1508851213
Name:FROEDTERT SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:FROEDTERT SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAITLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-777-0979
Mailing Address - Street 1:N74W12501 LEATHERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4490
Mailing Address - Country:US
Mailing Address - Phone:414-777-0417
Mailing Address - Fax:
Practice Address - Street 1:840 N 87TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3586
Practice Address - Country:US
Practice Address - Phone:414-805-9500
Practice Address - Fax:414-805-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2014993545261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41914400Medicaid
WI000085004Medicare ID - Type Unspecified