Provider Demographics
NPI:1851349674
Name:IHC-ST. ELIZABETH EMERGENCY PHYSICIANS, LLC
Entity Type:Organization
Organization Name:IHC-ST. ELIZABETH EMERGENCY PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-838-2371
Mailing Address - Street 1:111 E WISCONSIN AVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4815
Mailing Address - Country:US
Mailing Address - Phone:414-290-6718
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1305
Practice Address - Country:US
Practice Address - Phone:414-290-6718
Practice Address - Fax:414-290-6755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21287000Medicaid
WI140006669OtherWEA
WI610475600OtherOWCP
WI610475600OtherFEDERAL BLK LUNG PROGRAM
WI610475600OtherFEDERAL BLK LUNG PROGRAM
WI=========OtherTRICARE NORTH REGION
WI000045034Medicare ID - Type Unspecified