Provider Demographics
NPI:1912109893
Name:WILLIAM B. POTOS M.D. COMMONWEALTH MEDICAL GROUP
Entity Type:Organization
Organization Name:WILLIAM B. POTOS M.D. COMMONWEALTH MEDICAL GROUP
Other - Org Name:COMMONWEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTSCHELKNAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-777-5100
Mailing Address - Street 1:2500 W LAYTON AVE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5420
Mailing Address - Country:US
Mailing Address - Phone:414-281-9651
Mailing Address - Fax:
Practice Address - Street 1:2500 W LAYTON AVE
Practice Address - Street 2:SUITE 290
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5420
Practice Address - Country:US
Practice Address - Phone:414-281-9651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30862500Medicaid
WI30862500Medicaid