Provider Demographics
NPI:1558305284
Name:FROEDTERT SOUTH, INC.
Entity Type:Organization
Organization Name:FROEDTERT SOUTH, INC.
Other - Org Name:FROEDTERT SOUTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:262-577-8113
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53141-0130
Mailing Address - Country:US
Mailing Address - Phone:262-656-2930
Mailing Address - Fax:262-656-2749
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143
Practice Address - Country:US
Practice Address - Phone:262-656-2718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FROEDTERT SOUTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32815500Medicaid
WICR0320OtherMEDICARE RR
IL213742OtherMEDICARE
IL=========OtherMEDICAID
WI32815500Medicaid
WI000032250Medicare PIN