Provider Demographics
NPI:1669851770
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:FROEDTERT PHYSICIAN PARTNERS INC
Other - Org Type:Other Name
Authorized Official - Title/Position:INTERIM PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:P
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-805-3750
Mailing Address - Street 1:N74W12501 LEATHERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4490
Mailing Address - Country:US
Mailing Address - Phone:414-777-0417
Mailing Address - Fax:
Practice Address - Street 1:1701 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-9129
Practice Address - Country:US
Practice Address - Phone:262-626-4616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-21
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory