Provider Demographics
NPI:1669411567
Name:EAST TOWN PROFESSIONAL ASSOCIATES, S.C.
Entity type:Organization
Organization Name:EAST TOWN PROFESSIONAL ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:KEPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-241-3698
Mailing Address - Street 1:1017 W GLEN OAKS LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3371
Mailing Address - Country:US
Mailing Address - Phone:262-241-3698
Mailing Address - Fax:
Practice Address - Street 1:1017 W GLEN OAKS LN
Practice Address - Street 2:SUITE 201
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3371
Practice Address - Country:US
Practice Address - Phone:262-241-3698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42236200Medicaid