Healthcare Provider Details

I. General information

NPI: 1477546737
Provider Name (Legal Business Name): MEA-AEA KENOSHA SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 75TH ST
KENOSHA WI
53142-7884
US

IV. Provider business mailing address

PO BOX 637562 MEA-AEA KENOSH SC
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 262-948-5640
  • Fax: 440-842-8835
Mailing address:
  • Phone: 440-887-4718
  • Fax: 440-842-8835

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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN HOLTZCLAW
Title or Position: PRESIDENT
Credential: MD
Phone: 440-887-4718