Provider Demographics
NPI:1457528069
Name:FAMILY CARE MEDICAL CLINIC
Entity Type:Organization
Organization Name:FAMILY CARE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:P
Authorized Official - Last Name:QUARTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-732-2075
Mailing Address - Street 1:3123 SHORE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4287
Mailing Address - Country:US
Mailing Address - Phone:715-732-4120
Mailing Address - Fax:715-732-4430
Practice Address - Street 1:3123 SHORE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4287
Practice Address - Country:US
Practice Address - Phone:715-732-4120
Practice Address - Fax:715-732-4430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43060500Medicaid
WI523862Medicare Oscar/Certification