MEDICARE: ARCHWELL HEALTH PROFESSIONAL SERVICES OF WISCONSIN, SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207RC0000X	Cardiovascular Disease Physician
2	207Q00000X	Family Medicine Physician
3	363L00000X	Nurse Practitioner
4	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1164228797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARCHWELL HEALTH PROFESSIONAL SERVICES OF WISCONSIN, SC

Provider Business Mailing Address
First Line	:	102 WOODMONT BLVD STE 600
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37205-5250
Country	:	US
Telephone Number	:	888-987-1151
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 N MARTIN LUTHER KING DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2312
Country	:	US
Telephone Number	:	414-508-0002
Fax Number	:

Authorized Official
Title or Position	:	SR. DIRECTOR, MANAGED CARE OPS
Name	:	AMY MODDESETTE
Credential	:
Telephone Number	:	913-226-8221

Provider Enumeration Date	:	02/24/2025
Last Update Date	:	02/03/2026

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