Healthcare Provider Details

I. General information

NPI: 1902666035
Provider Name (Legal Business Name): COLAB PHYSICIANS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10325 N PORT WASHINGTON RD STE 150
MEQUON WI
53092-5768
US

IV. Provider business mailing address

6400 INDUSTRIAL LOOP
GREENDALE WI
53129-2452
US

V. Phone/Fax

Practice location:
  • Phone: 262-643-4720
  • Fax: 262-643-4720
Mailing address:
  • Phone: 414-858-4106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK W NIEDFELDT
Title or Position: PRESIDENT
Credential: MD
Phone: 262-643-4720