Provider Demographics
NPI:1467625178
Name:VANDERKOOY, KRIS RUDY
Entity Type:Individual
Prefix:MR
First Name:KRIS
Middle Name:RUDY
Last Name:VANDERKOOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 S SUNNY SLOPE RD
Mailing Address - Street 2:SUNNYSLOPE PRIMARY CARE CLINIC
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-7060
Mailing Address - Country:US
Mailing Address - Phone:414-805-9600
Mailing Address - Fax:414-805-9645
Practice Address - Street 1:1350 S SUNNY SLOPE RD
Practice Address - Street 2:SUNNYSLOPE PRIMARY CARE CLINIC
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-7060
Practice Address - Country:US
Practice Address - Phone:414-805-9600
Practice Address - Fax:414-805-9645
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467625178Medicaid
WI1467625178Medicaid
WI736012108Medicare PIN