Provider Demographics
NPI:1902215189
Name:BADGER MEDICAL GROUP S.C.
Entity Type:Organization
Organization Name:BADGER MEDICAL GROUP S.C.
Other - Org Name:DOCTORS EXPRESS WAUKESHA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOLZMACHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-202-1724
Mailing Address - Street 1:1700 CORAL DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1483
Mailing Address - Country:US
Mailing Address - Phone:262-232-6200
Mailing Address - Fax:262-232-6201
Practice Address - Street 1:1700 CORAL DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1483
Practice Address - Country:US
Practice Address - Phone:262-232-6200
Practice Address - Fax:262-232-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42642-020261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34749000Medicaid
WII10667Medicare UPIN