Provider Demographics
NPI:1922305077
Name:FAMILY MEDICINE & SURGERY LLC
Entity Type:Organization
Organization Name:FAMILY MEDICINE & SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:RENNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:262-642-7313
Mailing Address - Street 1:3066 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-1148
Mailing Address - Country:US
Mailing Address - Phone:262-642-7313
Mailing Address - Fax:262-642-4251
Practice Address - Street 1:3066 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120-1148
Practice Address - Country:US
Practice Address - Phone:262-642-7313
Practice Address - Fax:262-642-4251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26462208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508062043OtherTYPE 1 NPI
WI30100300Medicaid
WI26462OtherSTATE OF WISCONSIN LICENSE
WI80591OtherMEDICARE ID
WI80591OtherMEDICARE ID