Provider Demographics
NPI:1710020649
Name:ROCK RIVER FOOT & ANKLE CLINIC, SC
Entity Type:Organization
Organization Name:ROCK RIVER FOOT & ANKLE CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:SODERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-261-9610
Mailing Address - Street 1:101 OAKRIDGE CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4100
Mailing Address - Country:US
Mailing Address - Phone:920-261-9610
Mailing Address - Fax:920-261-9671
Practice Address - Street 1:153 E OAK ST
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:WI
Practice Address - Zip Code:53039-1323
Practice Address - Country:US
Practice Address - Phone:920-261-9610
Practice Address - Fax:920-261-9671
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROCK RIVER FOOT & ANKLE CLINIC, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-14
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43264800Medicaid