Healthcare Provider Details

I. General information

NPI: 1881783777
Provider Name (Legal Business Name): FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE SUITE 200W
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE SUITE 200W
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-5114
  • Fax: 414-805-7961
Mailing address:
  • Phone: 414-805-5114
  • Fax: 414-805-7961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number7501-042
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFERY R VAN DE KREEKE
Title or Position: SR. VICE PRESIDENT - FINANCE
Credential:
Phone: 414-777-0968