Healthcare Provider's Profile
| Full Name | |
|---|
| Type | Facility |
|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
|---|
| Location | 309 E North St, Waukesha, Wisconsin |
|---|
| Accepts Medicare Assignments | Does not participate in Medicare Program. The facility may not accept medicare assignment. |
|---|
NPI Data:
- NPI Number: 1083679385
- Provider Enumeration Date: 04/19/2006
- Last Update Date: 01/08/2025
Medical Identifiers
Medical identifiers for
such as npi, medicare ID, medicare PIN, medicaid, etc.
| Identifier | Type | State | Issuer |
|---|
| 1083679385 | NPI | - | NPPES |
| 32958300 | Medicaid | WI | |
Medical Taxonomies and Licenses
| Taxonomy | Type | License (State) | Status |
|---|
| 225100000X | Physical Therapist | (* (Not Available)) | Secondary |
| 225X00000X | Occupational Therapist | (* (Not Available)) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
Medicare Part D Prescriber Enrollment
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. is NOT enrolled with medicare and thus cannot prescribe medicare part D drugs to patients with medicare part D benefits.
Mailing Address and Practice Location
| Mailing Address | Practice Location Address |
|---|
2906 S 20th St,
Milwaukee, WI 53215-3732
Ph: (414) 672-1353 |
309 E North St,
Waukesha, WI 53188-3718
Ph: (414) 672-1353 |
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