Provider Demographics
NPI:1033288816
Name:NORTHWESTERN MEDICAL CENTER SC
Entity type:Organization
Organization Name:NORTHWESTERN MEDICAL CENTER SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:KURT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:262-631-0474
Mailing Address - Street 1:1532 S GREEN BAY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4410
Mailing Address - Country:US
Mailing Address - Phone:262-631-0474
Mailing Address - Fax:262-631-0476
Practice Address - Street 1:1532 S GREEN BAY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4410
Practice Address - Country:US
Practice Address - Phone:262-631-0474
Practice Address - Fax:262-631-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14968021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
38736439001OtherBCBS
WI30038200Medicaid
B54385Medicare UPIN