Provider Demographics
NPI:1457554990
Name:HARBOR MEDICAL & ASSOCIATES SC
Entity Type:Organization
Organization Name:HARBOR MEDICAL & ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-637-2050
Mailing Address - Street 1:4810 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-1504
Mailing Address - Country:US
Mailing Address - Phone:262-637-2050
Mailing Address - Fax:262-637-3910
Practice Address - Street 1:4810 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-1504
Practice Address - Country:US
Practice Address - Phone:262-637-2050
Practice Address - Fax:262-637-3910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25744-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30531900Medicaid
WIB57619Medicare UPIN
WI30531900Medicaid