Provider Demographics
NPI:1770558066
Name:INTERNAL MEDICINE & PEDIATRICS, S.C.
Entity type:Organization
Organization Name:INTERNAL MEDICINE & PEDIATRICS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-563-7711
Mailing Address - Street 1:500 MCMILLEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1233
Mailing Address - Country:US
Mailing Address - Phone:920-563-7711
Mailing Address - Fax:920-563-7705
Practice Address - Street 1:500 MCMILLEN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1233
Practice Address - Country:US
Practice Address - Phone:920-563-7711
Practice Address - Fax:920-563-7705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty