Provider Demographics
NPI:1356722045
Name:FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC.
Entity type:Organization
Organization Name:FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERHACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-805-6531
Mailing Address - Street 1:N86W12999 NIGHTINGALE WAY
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2102
Mailing Address - Country:US
Mailing Address - Phone:262-532-5173
Mailing Address - Fax:262-532-5105
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:CFAC PHARMACY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-1295
Practice Address - Fax:414-805-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
WI9309-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356722045Medicaid
2152531OtherPK