Provider Demographics
NPI:1568787448
Name:FROEDTERT &THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS, INC.
Entity Type:Organization
Organization Name:FROEDTERT &THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:ABBAS
Authorized Official - Last Name:GHAFERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-660-4939
Mailing Address - Street 1:N74W12501 LEATHERWOOD COURT
Mailing Address - Street 2:400 WOODLAND PRIME
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:W180N8000 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4002
Practice Address - Country:US
Practice Address - Phone:262-255-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FROEDTERT HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-02
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 251B00000X, 261QM1300X, 261QU0200X, 332B00000X, 332B00000X
WI52D2096793291U00000X
WI52D0388485291U00000X
WI52D2066480291U00000X
WI52D0678401291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1897Medicare PIN