Provider Demographics
NPI:1770095796
Name:MIDWEST INTEGRATED MEDICAL CENTER LLC
Entity type:Organization
Organization Name:MIDWEST INTEGRATED MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-808-0716
Mailing Address - Street 1:2920 ENLOE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8191
Mailing Address - Country:US
Mailing Address - Phone:715-808-0716
Mailing Address - Fax:
Practice Address - Street 1:2920 ENLOE ST STE 105
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8191
Practice Address - Country:US
Practice Address - Phone:715-808-0716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty