1639250210 NPI number — WHEATON FRANCISCAN MEDICAL GROUP

Table of content: (NPI 1639250210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639250210 NPI number — WHEATON FRANCISCAN MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHEATON FRANCISCAN MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639250210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19475 W NORTH AVE
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53045-4199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-780-4070
Provider Business Mailing Address Fax Number:
262-780-4050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19475 W NORTH AVE
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53045-4199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-780-4070
Provider Business Practice Location Address Fax Number:
262-780-4050
Provider Enumeration Date:
10/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WADE
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
414-465-3000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1013860011 . This is a "DME" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".