Provider Demographics
NPI:1821487620
Name:FMG NORTH 7TH STREET WISCONSIN LLC
Entity Type:Organization
Organization Name:FMG NORTH 7TH STREET WISCONSIN LLC
Other - Org Name:CORNELL AREA CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KEATING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-8058
Mailing Address - Street 1:320 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CORNELL
Mailing Address - State:WI
Mailing Address - Zip Code:54732-8120
Mailing Address - Country:US
Mailing Address - Phone:715-239-6288
Mailing Address - Fax:715-239-6608
Practice Address - Street 1:320 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CORNELL
Practice Address - State:WI
Practice Address - Zip Code:54732-8120
Practice Address - Country:US
Practice Address - Phone:715-239-6288
Practice Address - Fax:715-239-6608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525637Medicare Oscar/Certification