Basic Information
| Provider Information | |||||||||
| NPI: | 1902867005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UW HEALTH STOUGHTON NYGAARD CLINIC | ||||||||
| 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: | 6088330999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 NYGAARD ST | ||||||||
| Address2: | |||||||||
| City: | STOUGHTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535895495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088772660 | ||||||||
| FaxNumber: | 6088772667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 07/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | FLANNERY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CAO & CFO | ||||||||
| AuthorizedOfficialTelephone: | 6088214223 | ||||||||
| 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 | 41724500 | 05 | WI | MEDICAID |