Provider Demographics
NPI:1295810208
Name:FAMILY PRACTICE CLINIC OF MAYFAIR SC
Entity type:Organization
Organization Name:FAMILY PRACTICE CLINIC OF MAYFAIR SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:B
Authorized Official - Last Name:KNIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-258-5522
Mailing Address - Street 1:11803 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-258-5522
Mailing Address - Fax:414-258-1337
Practice Address - Street 1:11803 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-258-5522
Practice Address - Fax:414-258-1337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30074100Medicaid
WI000002135Medicare PIN