Provider Demographics
NPI:1720009459
Name:SUMMERSIDE, PAUL R (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:SUMMERSIDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2640
Mailing Address - Country:US
Mailing Address - Phone:920-327-7250
Mailing Address - Fax:920-327-7249
Practice Address - Street 1:2253 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4706
Practice Address - Country:US
Practice Address - Phone:920-327-7250
Practice Address - Fax:920-327-7249
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29836207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31449300Medicaid
WI31449300Medicaid
WI007507650Medicare ID - Type Unspecified