Provider Demographics
NPI:1831173699
Name:FACULTY PHYSICIANS OF INTERNAL MEDICINE, S.C.
Entity type:Organization
Organization Name:FACULTY PHYSICIANS OF INTERNAL MEDICINE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-649-7202
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:SUITE 730
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3669
Mailing Address - Country:US
Mailing Address - Phone:414-649-7202
Mailing Address - Fax:414-649-5158
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 730
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-649-7202
Practice Address - Fax:414-649-5158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207R00000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI29288OtherRAILROAD MEDICARE
WI21254500Medicaid
WI========= 010OtherBLUE CROSS BLUE SHEILD
WI21254500Medicaid