1396023198 NPI number — GREAT MIDWEST FOOT AND ANKLE CENTERS, S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396023198 NPI number — GREAT MIDWEST FOOT AND ANKLE CENTERS, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT MIDWEST FOOT AND ANKLE CENTERS, S.C.
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:
1396023198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8153 S 27TH ST
Provider Second Line Business Mailing Address:
400
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53132-9549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-761-0981
Provider Business Mailing Address Fax Number:
414-761-1614

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 W BROWN DEER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYSIDE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53217-2319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-761-0981
Provider Business Practice Location Address Fax Number:
414-761-1614
Provider Enumeration Date:
07/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MATTEUCCI
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
DONALD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-761-1613

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: 43237400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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