Provider Demographics
NPI:1134202062
Name:POUND COMMUNITY MEDICAL CLINIC S.C.
Entity type:Organization
Organization Name:POUND COMMUNITY MEDICAL CLINIC S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KELLOGG
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-897-2331
Mailing Address - Street 1:2026 COUNTY ROAD Q
Mailing Address - Street 2:
Mailing Address - City:POUND
Mailing Address - State:WI
Mailing Address - Zip Code:54161-9707
Mailing Address - Country:US
Mailing Address - Phone:920-897-2331
Mailing Address - Fax:920-897-2115
Practice Address - Street 1:2026 COUNTY ROAD Q
Practice Address - Street 2:
Practice Address - City:POUND
Practice Address - State:WI
Practice Address - Zip Code:54161-9707
Practice Address - Country:US
Practice Address - Phone:920-897-2331
Practice Address - Fax:920-897-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25995174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32721700Medicaid
WI0429860001Medicare NSC
WIB54951Medicare UPIN