1164700027 NPI number — TRINITY INTEGRATIVE FAMILY MEDICINE

Table of content: (NPI 1164700027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164700027 NPI number — TRINITY INTEGRATIVE FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRINITY INTEGRATIVE FAMILY MEDICINE
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:
1164700027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
S72W13575 WOODS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUSKEGO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53150-3707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-427-1577
Provider Business Mailing Address Fax Number:
414-427-1577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15350 W NATIONAL AVE
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
NEW BERLIN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53151-5158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-782-9541
Provider Business Practice Location Address Fax Number:
262-782-6541
Provider Enumeration Date:
07/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KOCOUREK
Authorized Official First Name:
GENEVIE
Authorized Official Middle Name:
LOREE
Authorized Official Title or Position:
DIRECTOR/OWNER
Authorized Official Telephone Number:
414-427-1577

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  53754 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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