Healthcare Provider Details

I. General information

NPI: 1164637492
Provider Name (Legal Business Name): ELKHORN FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S WASHINGTON ST
ELKHORN WI
53121-1732
US

IV. Provider business mailing address

100 S WASHINGTON ST
ELKHORN WI
53121-1732
US

V. Phone/Fax

Practice location:
  • Phone: 262-743-1122
  • Fax: 262-743-1582
Mailing address:
  • Phone: 262-743-1122
  • Fax: 262-743-1582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number43819-020
License Number StateWI

VIII. Authorized Official

Name: DR. KAMAL SYED MUZAFFAR
Title or Position: CEO
Credential: MD
Phone: 262-743-1122