Provider Demographics
NPI:1245372994
Name:INTERNAL MEDICINE CLINIC SC
Entity type:Organization
Organization Name:INTERNAL MEDICINE CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-567-0227
Mailing Address - Street 1:1229 ROBRUCK DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4446
Mailing Address - Country:US
Mailing Address - Phone:262-567-0227
Mailing Address - Fax:262-567-0229
Practice Address - Street 1:1229 ROBRUCK DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4446
Practice Address - Country:US
Practice Address - Phone:262-567-0227
Practice Address - Fax:262-567-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21232261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care