Healthcare Provider Details

I. General information

NPI: 1134303621
Provider Name (Legal Business Name): SOUTHEASTERN FAMILY PRACTICE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 S 16TH ST
MILWAUKEE WI
53204-2711
US

IV. Provider business mailing address

8532 W CAPITOL DR
MILWAUKEE WI
53222-1848
US

V. Phone/Fax

Practice location:
  • Phone: 414-831-0100
  • Fax: 414-831-1584
Mailing address:
  • Phone: 414-463-6640
  • Fax: 414-463-6743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number48505
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number26529
License Number StateWI

VIII. Authorized Official

Name: DR. NOEMI A PRIETO
Title or Position: PRESIDENT
Credential: MD
Phone: 414-463-6640