Provider Demographics
NPI:1558832055
Name:HOMETOWN PHYSICIAN SERVICES MD, S.C.
Entity Type:Organization
Organization Name:HOMETOWN PHYSICIAN SERVICES MD, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MSO ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-304-2262
Mailing Address - Street 1:401 FINVOLD ST
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54028-9719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 FINVOLD ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:WI
Practice Address - Zip Code:54028
Practice Address - Country:US
Practice Address - Phone:617-304-2262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-09
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty