Provider Demographics
NPI:1801100243
Name:CSM COMMUNITY PHYSICIAN
Entity type:Organization
Organization Name:CSM COMMUNITY PHYSICIAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BJORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-298-7284
Mailing Address - Street 1:PO BOX 78309
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-0001
Mailing Address - Country:US
Mailing Address - Phone:414-298-7280
Mailing Address - Fax:414-298-7281
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7280
Practice Address - Fax:414-298-7281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBIA ST MARYS HOSPITAL MILWAUKEE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-27
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32793800Medicaid