Provider Demographics
NPI:1265634331
Name:DOUSMAN CLINIC, S.C.
Entity Type:Organization
Organization Name:DOUSMAN CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:REIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-494-9661
Mailing Address - Street 1:124 SIEGLER ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2636
Mailing Address - Country:US
Mailing Address - Phone:920-494-9661
Mailing Address - Fax:
Practice Address - Street 1:124 SIEGLER ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2636
Practice Address - Country:US
Practice Address - Phone:920-494-9661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32786100Medicaid
WI32786100Medicaid