Provider Demographics
NPI:1508936154
Name:NORTHEAST OBGYN SC
Entity Type:Organization
Organization Name:NORTHEAST OBGYN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:FAIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-228-8888
Mailing Address - Street 1:7040 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3838
Mailing Address - Country:US
Mailing Address - Phone:414-228-8888
Mailing Address - Fax:414-228-8390
Practice Address - Street 1:7040 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 400
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3838
Practice Address - Country:US
Practice Address - Phone:414-228-8888
Practice Address - Fax:414-228-8390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207V00000X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31388400Medicaid
B52695Medicare UPIN
000102810Medicare ID - Type Unspecified