Provider Demographics
NPI:1376527002
Name:KRECKMAN, SUSAN H (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:KRECKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 NEW PINERY RD.
Mailing Address - Street 2:DIVINE SAVIOR HEALTHCARE, INC.
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:608-745-4598
Mailing Address - Fax:608-745-6242
Practice Address - Street 1:2817 NEW PINERY RD.
Practice Address - Street 2:DIVINE SAVIOR HEALTHCARE, INC.
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-0387
Practice Address - Country:US
Practice Address - Phone:608-745-4598
Practice Address - Fax:608-745-6242
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI39356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32379600Medicaid
WI32379600Medicaid
G57537Medicare UPIN