Provider Demographics
NPI:1346213980
Name:GREAT LAKES PLASTIC SURGERY SC
Entity Type:Organization
Organization Name:GREAT LAKES PLASTIC SURGERY SC
Other - Org Name:JEFFREY A HEROLD MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PLASTIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEROLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-803-1598
Mailing Address - Street 1:1526 N TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1927
Mailing Address - Country:US
Mailing Address - Phone:920-803-1598
Mailing Address - Fax:920-803-1599
Practice Address - Street 1:1526 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1927
Practice Address - Country:US
Practice Address - Phone:920-803-1598
Practice Address - Fax:920-803-1599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39578020208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32429800Medicaid
WI000060300Medicare ID - Type Unspecified
WI000060161Medicare ID - Type Unspecified
WI32429800Medicaid