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General NPI Number Information
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NPI Number | 1104711605
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Entity Type | Organization
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Legal Business Name | SOLIDARITUS HEALTH WISCONSIN SC
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Dates
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Enumeration Date | 06/12/2025
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 915 SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066-3921
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Country | US
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Telephone | 414-348-8970
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Fax |
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Provider Business Mailing Address
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Address Line | 1025 CONNECTICUT AVE NW STE 907
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City | WASHINGTON
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State | DC
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Zip | 20036-5434
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Country | US
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Telephone | 888-491-2951
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | GEORGIA JAQUETTE SMITH
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Credential |
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Telephone | 715-461-0463
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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