NPIMap

Organization Active NPI

Wildwood Family Clinic, SC

  • Family Medicine Physician
  • Cottage Grove, WI
National Provider Identifier
1225115124
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
WILDWOOD FAMILY CLINIC, SC
Practice address
535 Southing Grange
Cottage Grove, WI 53527-9338
Phone
(608) 839-3515
Fax
(608) 839-3541
NPI assigned
Nov 1, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Sheryl Green
Title
Administrator
Phone
(608) 221-1501

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

535 Southing Grange
Cottage Grove, WI 53527-9338

Mailing address

535 Southing Grange
Cottage Grove, WI 53527-9338
Phone (608) 839-3515

Other identifiers 1

IdentifierTypeStateIssuer
32721000MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040920000493 WI Part B Supplier - Clinic/Group Practice 9537137484 Receives reassigned benefits from 31 practitioners
1 other NPI on this enrollment
Practice locations: Madison, WI

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

535 Southing Grange
Cottage Grove, WI 53527
Phone (608) 221-1501

Practitioners & affiliated clinicians

Practitioners 31

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 31

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1225115124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "535 SOUTHING GRANGE",
            "city": "COTTAGE GROVE",
            "state": "WI",
            "postal_code": "535279338",
            "telephone_number": "608-839-3515",
            "fax_number": "608-839-3541"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "535 SOUTHING GRANGE",
            "city": "COTTAGE GROVE",
            "state": "WI",
            "postal_code": "535279338",
            "telephone_number": "608-839-3515",
            "fax_number": "608-839-3541"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILDWOOD FAMILY CLINIC, SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-01",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "GREEN",
        "authorized_official_first_name": "SHERYL",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "608-221-1501"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32721000",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Cottage Grove, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.