MEDICARE: FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC.

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
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1649626540
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC.

Provider Business Mailing Address
First Line	:	W126N7338 FLINT DR
Second Line	:
City	:	MENOMONEE FALLS
State	:	WI
Zip	:	53051-4532
Country	:	US
Telephone Number	:	262-253-5105
Fax Number	:	262-253-5152

Provider Business Practice Location Address
First Line	:	7725 W NORTH AVE
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-1720
Country	:	US
Telephone Number	:	414-777-3406
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR BUSINESS DEVELOPMENT
Name	:	BARBRA FAGAN
Credential	:
Telephone Number	:	262-253-5105

Provider Enumeration Date	:	05/10/2016
Last Update Date	:	07/20/2016

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