Provider Demographics
NPI:1902666035
Name:COLAB PHYSICIANS, SC
Entity Type:Organization
Organization Name:COLAB PHYSICIANS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:NIEDFELDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-643-4720
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-858-4106
Mailing Address - Fax:
Practice Address - Street 1:10325 N PORT WASHINGTON RD STE 150
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5768
Practice Address - Country:US
Practice Address - Phone:262-643-4720
Practice Address - Fax:262-643-4720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty