Provider Demographics
NPI:1225022254
Name:STANIS, GEORGE R (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:R
Last Name:STANIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1846
Mailing Address - Country:US
Mailing Address - Phone:920-730-4435
Mailing Address - Fax:
Practice Address - Street 1:1501 S MADISON ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1846
Practice Address - Country:US
Practice Address - Phone:920-730-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23257208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30317800Medicaid
WI0054 45300Medicare PIN
B56825Medicare UPIN
WI0188 71018Medicare PIN