Provider Demographics
NPI:1649230475
Name:UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
Other - Org Name:UW HEALTH AUGUSTA FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-263-7013
Mailing Address - Street 1:7974 UW HEALTH COURT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:608-829-5270
Mailing Address - Fax:608-833-5039
Practice Address - Street 1:207 W LINCOLN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:AUGUSTA
Practice Address - State:WI
Practice Address - Zip Code:54722-9156
Practice Address - Country:US
Practice Address - Phone:715-286-2270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41753700Medicaid
WI41753700Medicaid