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NPI Code Detail

MEDICARE: PADDOCK LAKE FAMILY PRACTICE, SC

MEDICARE: PADDOCK LAKE FAMILY PRACTICE, SC
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1DD7478OTHERRAIL ROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1417919275
Entity Type Code : Organization
Provider Name (Legal Business Name) : PADDOCK LAKE FAMILY PRACTICE, SC
Provider Business Mailing Address
First Line : 7137 236TH AVE
Second Line : SUITE 103
City : SALEM
State : WI
Zip : 53168-9664
Country : US
Telephone Number : 262-843-4422
Fax Number : 262-843-1166
Provider Business Practice Location Address
First Line : 7137 236TH AVE
Second Line : SUITE 103
City : SALEM
State : WI
Zip : 53168-9664
Country : US
Telephone Number : 262-843-4422
Fax Number : 262-843-1166
Authorized Official
Title or Position : BILLING MANAGER
Name : MS. LISA M THOMAS
Credential :
Telephone Number : 262-843-2394
Provider Enumeration Date : 04/05/2006
Last Update Date : 04/20/2008

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Directions to “PADDOCK LAKE FAMILY PRACTICE, SC ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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