MEDICARE: GOODWILL INDUSTRIES OF SOUTHEASTERN WISCONSIN, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1306027578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODWILL INDUSTRIES OF SOUTHEASTERN WISCONSIN, INC.

Provider Business Mailing Address
First Line	:	6055 N 91ST ST
Second Line	:	P.O. BOX 250973
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-1710
Country	:	US
Telephone Number	:	414-353-6400
Fax Number	:	414-358-4283

Provider Business Practice Location Address
First Line	:	6055 N 91ST ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-1710
Country	:	US
Telephone Number	:	414-353-6400
Fax Number	:	414-358-4283

Authorized Official
Title or Position	:	VICE PRESIDENT AND CFO
Name	:	MR. CHARLES J. STADLER
Credential	:
Telephone Number	:	414-358-4319

Provider Enumeration Date	:	11/16/2007
Last Update Date	:	11/16/2007

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