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General NPI Number Information
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NPI Number | 1518976919
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Entity Type | Organization
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Legal Business Name | WEST BEND CLINIC
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 05/23/2012
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Provider Practice Location Address
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Address Line | 1701 FOND DU LAC AVE
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City | KEWASKUM
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State | WI
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Zip | 53040-9129
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Country | US
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Telephone | 262-626-4616
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Fax |
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Provider Business Mailing Address
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Address Line | 1700 W PARADISE DR
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City | WEST BEND
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State | WI
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Zip | 53095-9795
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Country | US
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Telephone | 262-334-3451
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | GREGORY G BLOMMEL
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Credential |
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Telephone | 262-334-3451
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2085B0100X
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Taxonomy Name | Body Imaging Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #5
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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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