Provider Demographics
NPI:1043344203
Name:WAUKESHA FAMILY PRACTICE CENTER
Entity type:Organization
Organization Name:WAUKESHA FAMILY PRACTICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:PURDY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:262-548-6916
Mailing Address - Street 1:210 NW BARSTOW ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3771
Mailing Address - Country:US
Mailing Address - Phone:262-548-6903
Mailing Address - Fax:262-928-4075
Practice Address - Street 1:210 NW BARSTOW ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3771
Practice Address - Country:US
Practice Address - Phone:262-548-6903
Practice Address - Fax:262-928-4075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32739000Medicaid
WI68086Medicare ID - Type Unspecified