Provider Demographics
NPI:1265544498
Name:AFFILIATED ENT, SC
Entity type:Organization
Organization Name:AFFILIATED ENT, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-475-9300
Mailing Address - Street 1:N87W16462 JACOBSON DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2833
Mailing Address - Country:US
Mailing Address - Phone:262-255-1040
Mailing Address - Fax:262-255-4090
Practice Address - Street 1:2500 N MAYFAIR RD STE 450
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1443
Practice Address - Country:US
Practice Address - Phone:414-475-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty