Provider Demographics
NPI:1770663221
Name:FAMILY MEDICAL CLINIC, S.C.
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KLUGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-262-4784
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-0110
Mailing Address - Country:US
Mailing Address - Phone:920-262-4784
Mailing Address - Fax:
Practice Address - Street 1:1507 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4101
Practice Address - Country:US
Practice Address - Phone:920-261-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21266600Medicaid