Provider Demographics
NPI:1205928553
Name:ELMBROOK INTERNAL MEDICINE ASSOCIATES S.C.
Entity type:Organization
Organization Name:ELMBROOK INTERNAL MEDICINE ASSOCIATES S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-782-4270
Mailing Address - Street 1:17000 W NORTH AVE
Mailing Address - Street 2:SUITE 200E
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4423
Mailing Address - Country:US
Mailing Address - Phone:262-782-4270
Mailing Address - Fax:262-784-9319
Practice Address - Street 1:17000 W NORTH AVE
Practice Address - Street 2:SUITE 200E
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4423
Practice Address - Country:US
Practice Address - Phone:262-782-4270
Practice Address - Fax:262-784-9319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26997261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32742000Medicaid
WI32742000Medicaid
WI=========010OtherBLUE CROSS BLUE SHIELD