Healthcare Provider Details

I. General information

NPI: 1457799975
Provider Name (Legal Business Name): FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W225N16711 CEDAR PARK CT
JACKSON WI
53037-9222
US

IV. Provider business mailing address

WOODLAND PRIME 400 SUITE 103 N74 W12501 LEATHERWOOD COURT
MENOMONEE FALLS WI
53051-4490
US

V. Phone/Fax

Practice location:
  • Phone: 262-677-1101
  • Fax: 262-677-0121
Mailing address:
  • Phone: 414-777-0417
  • Fax: 414-777-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: AMIR ABBAS GHAFERI
Title or Position: PRESIDENT & CEO
Credential: MD
Phone: 734-660-4939