| NPI |
1225476740 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
| Entity Type Code |
2 |
The first name of the provider, if the provider
is an individual. |
| Employer Identification Number EIN |
|
The middle name of the provider, if the provider
is an individual. |
| Provider Organization Name Legal Business Name |
FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN COMMUNITY PHYSICIANS INC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider First Line Business Practice Location Address |
1700 W PARADISE DR |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name |
WEST BEND |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
WI |
The State code in the location of the provider
being identified. |
| Provider Business Practice Location Address Postal Code |
530959795 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address Telephone Number |
2623343451 |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address Fax Number |
2623345321 |
The State code in the location of the provider
being identified. |
| Provider Enumeration Date |
6/6/2013 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Last Update Date |
6/26/2023 |
The country code in the location address of the provider being identified. |
| Authorized Official Last Name |
GHAFERI |
The code designating the provider’s gender if the provider is a person. |
| Authorized Official First Name |
AMIR |
The first name of the authorized official. |
| Authorized Official Middle Name |
ABBAS |
The middle name of the authorized official. |
| Authorized Official Title or Position |
PRESIDENT & CEO |
The title or position of the authorized official. |
| Authorized Official Telephone Number |
7346604939 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| Healthcare Provider Taxonomy Code 1 |
332B00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Other Provider Identifier 1 |
6521570012 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 1 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Issuer 1 |
MEDICARE DME CONTRACTOR |
|
| Is Organization Subpart |
N |
|
| Authorized Official Credential Text |
MD |
|
| NPI Certification Date |
6/26/2023 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |