| Providence Family Medical Clinic S.c | |
|
2500 W Silver Spring Dr Glendale WI 53209-4218 | |
| (414) 800-7171 | |
| (414) 800-7166 |
| Full Name | Providence Family Medical Clinic S.c |
|---|---|
| Speciality | Clinic/Center |
| Location | 2500 W Silver Spring Dr, Glendale, Wisconsin |
| Authorized Official Name and Position | Adedapo F Okusanya (PRESIDENT) |
| Authorized Official Contact | 2695987404 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Family Medical Clinic S.c 2500 W Silver Spring Dr Glendale WI 53209-4218 Ph: (414) 800-7171 | Providence Family Medical Clinic S.c 2500 W Silver Spring Dr Glendale WI 53209-4218 Ph: (414) 800-7171 |
| NPI Number | 1861857542 |
|---|---|
| Provider Enumeration Date | 12/22/2015 |
| Last Update Date | 12/22/2015 |
| Medicare PECOS PAC ID | 3173828142 |
|---|---|
| Medicare Enrollment ID | O20160229002957 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1861857542 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Olalekan Lukman Ganiyu |
|---|---|
| Provider Type | Practitioner - Physical Therapist In Private Practice |
| Provider Identifiers | NPI Number: 1366548919 PECOS PAC ID: 2860464039 Enrollment ID: I20040809000662 |
| Provider Name | Adedapo F Okusanya |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1619932126 PECOS PAC ID: 1355357740 Enrollment ID: I20060222000267 |
| Provider Name | Nathanael P Sorum |
|---|---|
| Provider Type | Practitioner - Physical Therapist In Private Practice |
| Provider Identifiers | NPI Number: 1871881094 PECOS PAC ID: 0648435396 Enrollment ID: I20120629000549 |
| Provider Name | Caryl A Giuliani |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1780967729 PECOS PAC ID: 0749436145 Enrollment ID: I20120816000770 |
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