=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972856169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST FOOT AND WOUND CARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2012
-----------------------------------------------------
Last Update Date | 04/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 355 N PETERS AVE STE 3
-----------------------------------------------------
City | FOND DU LAC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54935-8115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-539-5400
-----------------------------------------------------
Fax | 920-486-7070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6400 INDUSTRIAL LOOP
-----------------------------------------------------
City | GREENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53129-2452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-423-4110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIA E SALEH
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 920-539-1902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 801-25
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------