Provider Demographics
NPI:1740274687
Name:WAUKESHA FAMILY PRACTICE CLINIC, LTD.
Entity type:Organization
Organization Name:WAUKESHA FAMILY PRACTICE CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BEAUMONT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:262-542-5557
Mailing Address - Street 1:237 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4955
Mailing Address - Country:US
Mailing Address - Phone:262-542-5557
Mailing Address - Fax:262-542-6199
Practice Address - Street 1:237 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4955
Practice Address - Country:US
Practice Address - Phone:262-542-5557
Practice Address - Fax:262-542-6199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21266500Medicaid
WI21266500Medicaid