Provider Demographics
NPI:1043263007
Name:ROCK RIVER FOOT & ANKLE CLINIC, SC
Entity Type:Organization
Organization Name:ROCK RIVER FOOT & ANKLE CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:SODERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-261-9610
Mailing Address - Street 1:101 OAKRIDGE CT
Mailing Address - Street 2:STE A
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4150
Mailing Address - Country:US
Mailing Address - Phone:920-261-9610
Mailing Address - Fax:920-261-9671
Practice Address - Street 1:101 OAKRIDGE CT
Practice Address - Street 2:STE A
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4150
Practice Address - Country:US
Practice Address - Phone:920-261-9610
Practice Address - Fax:920-261-9671
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROCK RIVER FOOT & ANKLE CLINIC, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43264800Medicaid
WI000046460Medicare PIN
WI000086435Medicare PIN
WI0541050001Medicare NSC