Healthcare Provider Details

I. General information

NPI: 1639608177
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: 06/08/2017
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1271 N 6TH ST
MILWAUKEE WI
53212-3360
US

IV. Provider business mailing address

N74W12501 LEATHERWOOD CT
MENOMONEE FALLS WI
53051-4490
US

V. Phone/Fax

Practice location:
  • Phone: 414-978-9100
  • Fax:
Mailing address:
  • Phone: 414-777-0417
  • Fax:

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