1003909847 NPI number — WHITEFISH BAY FOOT & ANKLE CLINC, LLC

Table of content: (NPI 1003909847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003909847 NPI number — WHITEFISH BAY FOOT & ANKLE CLINC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITEFISH BAY FOOT & ANKLE CLINC, LLC
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:
1003909847
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11430
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53211-0430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-962-9070
Provider Business Mailing Address Fax Number:
414-962-9050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 E SILVER SPRING DR STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITEFISH BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53217-4704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-967-1900
Provider Business Practice Location Address Fax Number:
414-967-1926
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOUDREAU
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
PODIATRIST / OWNER
Authorized Official Telephone Number:
414-967-1900

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 43266800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com