Provider Demographics
NPI:1023119666
Name:GREENDALE MEDICAL CLINIC, S.C.
Entity type:Organization
Organization Name:GREENDALE MEDICAL CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUBING
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:414-423-0555
Mailing Address - Street 1:6601 NORTHWAY # D
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1830
Mailing Address - Country:US
Mailing Address - Phone:414-423-0555
Mailing Address - Fax:414-423-8268
Practice Address - Street 1:6601 NORTHWAY # D
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1830
Practice Address - Country:US
Practice Address - Phone:414-423-0555
Practice Address - Fax:414-423-8268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32688400Medicaid
WI32688400Medicaid