Provider Demographics
NPI:1326020629
Name:NORTHSHORE CLINIC OF SHEBOYGAN INC
Entity Type:Organization
Organization Name:NORTHSHORE CLINIC OF SHEBOYGAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALOG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:920-457-8866
Mailing Address - Street 1:615 S 8TH ST
Mailing Address - Street 2:STE G20
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4405
Mailing Address - Country:US
Mailing Address - Phone:920-457-8866
Mailing Address - Fax:920-457-8867
Practice Address - Street 1:615 S 8TH ST
Practice Address - Street 2:STE G20
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4405
Practice Address - Country:US
Practice Address - Phone:920-457-8866
Practice Address - Fax:920-457-8867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42233600Medicaid
WI42233600Medicaid