Provider Demographics
NPI:1851300784
Name:WILDWOOD FAMILY CLINIC SC
Entity Type:Organization
Organization Name:WILDWOOD FAMILY CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-221-1501
Mailing Address - Street 1:4901 COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1392
Mailing Address - Country:US
Mailing Address - Phone:608-221-1501
Mailing Address - Fax:608-223-3540
Practice Address - Street 1:4901 COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-1392
Practice Address - Country:US
Practice Address - Phone:608-221-1501
Practice Address - Fax:608-223-3540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty