Organization
FROEDTERT SOUTH, INC.
Active
Parent organization
FROEDTERT SOUTH, INC.
Other names
Froedtert South Medical Group
Organization subpart
Yes
Provider details
NPI number
Legal business name
FROEDTERT SOUTH, INC.
Authorized official
MR. THOMAS J KELLEY III (VICE PRESIDENT & CFO)
(262) 577-8113
Entity
Organization
Contact information
Practice address
6308 8TH AVE, KENOSHA, WI 53143
(262) 656-2718
Mailing address
PO BOX 130, KENOSHA, WI 53141-0130
(262) 656-2930
(262) 656-2749
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
261Q00000X
Clinic/Center
—
—
261QM1300X
Multi-Specialty Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
213742
MEDICARE
IL
05
—
32815500
—
WI
01
—
CR0320
MEDICARE RR
WI
Enumeration date
06/15/2006
Last updated
03/15/2023
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