Healthcare Provider Details

I. General information

NPI: 1598102717
Provider Name (Legal Business Name): EMERGENCY MEDICINE OF RACINE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3807 SPRING ST
MOUNT PLEASANT WI
53405-1667
US

IV. Provider business mailing address

307 S EVERGREEN AVE
WOODBURY NJ
08096-2739
US

V. Phone/Fax

Practice location:
  • Phone: 262-687-8150
  • Fax:
Mailing address:
  • Phone: 856-686-4306
  • Fax:

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 G HOLTZCLAW
Title or Position: PRESIDENT
Credential: MD
Phone: 954-377-2927