Community Pediatrics SC
Organization Active NPI Pediatrics Physician · Beaver Dam, WI
NPI 1275749566 · NPPES record last updated Apr 8, 2010
Key facts
- NPI
- 1275749566
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pediatrics Physician 208000000X
- Legal business name
- COMMUNITY PEDIATRICS SC
- Practice address
- 109 Warren St Ste 4
Beaver Dam, WI 53916-3082 - Phone
- (920) 885-3305
- Fax
- (920) 885-5506
- NPI assigned
- May 15, 2007
- Organization subpart
- No
Authorized official
- Name
- Ms. Dorothy Jean Larson
- Title
- Account Manager
- Phone
- (920) 885-3305
Practitioners 6
-
Jay M Miesfeld, M.D.
-
Laura Jane Lerwick, APNP
-
Brittany N Vanden Heuvel, APNP
-
Jessica L Miesfeld, M.D.
-
Laura M Pierre, CPNP
-
Kaitlyn N Pufahl, CPNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050725000693 | WI | Part B Supplier - Clinic/Group Practice | 8729015409 |
Receives reassigned benefits from 1 practitioner Practice locations: Waupun, WI; Beaver Dam, WI |
National Provider Directory
Locations
109 Warren St
Ste 3
Beaver Dam, WI 53916
Phone (920) 885-3305
109 Warren St
Ste 4
Beaver Dam, WI 53916
Phone (608) 915-0150
608 W Brown St
Ste 2
Waupun, WI 53963
Phone (920) 239-2200
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | Yes | ||
| Pediatric Nurse Practitioner |
363LP0200X |
Addresses
Primary practice location
109 Warren St Ste 4
Beaver Dam, WI 53916-3082
Mailing address
109 Warren St Ste 4
Beaver Dam, WI 53916-3082
Phone (920) 885-3305
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 34638800 | Medicaid | WI |
Other providers in Beaver Dam, WI
- City of Beaver Dam Et Al
- Susan Dorsch Clark
- Richard Clutson
- Edward F Cody
- Robert A Coe
- Daniel Conard
- Consultants Laboratory of Wisconsin, LLC
- Debra Lynn Conway
- Mischa Renee Cordle
- Laura Ellen Correa
All providers in Beaver Dam, WI · Pediatrics Physician in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 8, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.