Basic Information
| Provider Information | |||||||||
| NPI: | 1528028362 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UW HEALTH WINGRA FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7974 UW HEALTH COURT | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535625531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088295270 | ||||||||
| FaxNumber: | 6088336965 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 DANE ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537131900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082633111 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/24/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/02/2009 | ||||||||
| NPIReactivationDate: | 07/24/2009 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KINSELLA | ||||||||
| AuthorizedOfficialFirstName: | CONNIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6088295270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 41728600 | 05 | WI | MEDICAID |