=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710928221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2006
-----------------------------------------------------
Last Update Date | 03/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13111 N PORT WASHINGTON RD
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53097-2416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-270-4932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4425 N PORT WASHINGTON RD
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53212-1082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-326-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MICHAEL MCCULLOUGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-465-3736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------