Provider Demographics
NPI:1679797146
Name:WILLIAM B. POTOS M.D. FAMILY MEDICINE
Entity Type:Organization
Organization Name:WILLIAM B. POTOS M.D. FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:POTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-281-9651
Mailing Address - Street 1:2500 W LAYTON AVE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5420
Mailing Address - Country:US
Mailing Address - Phone:414-281-9651
Mailing Address - Fax:
Practice Address - Street 1:2500 W LAYTON AVE
Practice Address - Street 2:SUITE 290
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5420
Practice Address - Country:US
Practice Address - Phone:414-281-9651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14134261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30862500Medicaid
WI048973840Medicare Oscar/Certification
WIB55818Medicare UPIN
WI000004003Medicare ID - Type Unspecified
WI044668480Medicare Oscar/Certification