Basic Information
Provider Information
NPI: 1598784555
EntityType: 2
ReplacementNPI:  
OrganizationName: UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION, INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7974 UW HEALTH COURT
Address2:  
City: MIDDLETON
State: WI
PostalCode: 535625531
CountryCode: US
TelephoneNumber: 6088295485
FaxNumber: 6088330999
Practice Location
Address1: 7974 UW HEALTH COURT
Address2:  
City: MIDDLETON
State: WI
PostalCode: 535625531
CountryCode: US
TelephoneNumber: 6088295485
FaxNumber: 6088330999
Other Information
ProviderEnumerationDate: 07/19/2006
LastUpdateDate: 06/02/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FLANNERY
AuthorizedOfficialFirstName: ROBERT
AuthorizedOfficialMiddleName: W
AuthorizedOfficialTitleorPosition: CAO AND CFO
AuthorizedOfficialTelephone: 6088214223
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM1300X  Y Ambulatory Health Care FacilitiesClinic/CenterMulti-Specialty

ID Information
IDTypeStateIssuerDescription
3274390005WI MEDICAID


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