Healthcare Provider Details

I. General information

NPI: 1922056761
Provider Name (Legal Business Name): IHC-CALUMET EMERGENCY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 MEMORIAL DR
CHILTON WI
53014-1568
US

IV. Provider business mailing address

111 E WISCONSIN AVE SUITE 2000
MILWAUKEE WI
53202-4815
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6720
  • Fax: 414-290-6755
Mailing address:
  • Phone: 414-290-6720
  • Fax: 414-290-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: GREGORY A CIERLIK
Title or Position: PRESIDENT & CHIEF OPERATING OFFICER
Credential:
Phone: 414-290-6700