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General NPI Number Information
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NPI Number | 1861857542
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Entity Type | Organization
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Legal Business Name | PROVIDENCE FAMILY MEDICAL CLINIC S.C
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Dates
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Enumeration Date | 12/22/2015
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Last Update Date | 12/22/2015
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Provider Practice Location Address
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Address Line | 2500 W SILVER SPRING DR
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City | GLENDALE
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State | WI
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Zip | 53209-4218
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Country | US
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Telephone | 414-800-7171
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Fax | 414-800-7166
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Provider Business Mailing Address
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Address Line | 2500 W SILVER SPRING DR
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City | GLENDALE
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State | WI
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Zip | 53209-4218
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Country | US
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Telephone | 414-800-7171
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Fax | 414-800-7166
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ADEDAPO F OKUSANYA
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Credential | M.D.
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Telephone | 269-598-7404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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