Provider Demographics
NPI:1013450006
Name:FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC.
Entity Type:Organization
Organization Name:FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC.
Other - Org Name:FROEDTERT HOSPITAL RAYUS RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT, FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAITLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-777-0979
Mailing Address - Street 1:N74W12501 LEATHERWOOD CT
Mailing Address - Street 2:400 WOODLAND PRIME
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4490
Mailing Address - Country:US
Mailing Address - Phone:414-777-0417
Mailing Address - Fax:
Practice Address - Street 1:W129N7055 NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-0538
Practice Address - Country:US
Practice Address - Phone:262-251-5305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-23
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0200X
WI279,232282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI520177OtherMEDICARE ID