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General NPI Number Information
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NPI Number | 1164700027
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Entity Type | Organization
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Legal Business Name | TRINITY INTEGRATIVE FAMILY MEDICINE
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Dates
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Enumeration Date | 07/26/2011
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Last Update Date | 08/15/2011
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Provider Practice Location Address
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Address Line | 15350 W NATIONAL AVE SUITE 212
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City | NEW BERLIN
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State | WI
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Zip | 53151-5158
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Country | US
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Telephone | 262-782-9541
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Fax | 262-782-6541
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Provider Business Mailing Address
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Address Line | S72W13575 WOODS RD
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City | MUSKEGO
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State | WI
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Zip | 53150-3707
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Country | US
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Telephone | 414-427-1577
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Fax | 414-427-1577
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Authorized Official
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Title or Position | DIRECTOR/OWNER
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Name | GENEVIE LOREE KOCOUREK
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Credential | M.D.
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Telephone | 414-427-1577
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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 | 53754
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License Number State | WI
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