Provider Demographics
NPI:1902814932
Name:FOSSUM, JANE E (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:E
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 HUEBBE PKWY
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2293
Mailing Address - Fax:608-364-2700
Practice Address - Street 1:1905 HUEBBE PKWY
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-2293
Practice Address - Fax:608-364-2700
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI20990020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
10637OtherDEAN HEALTH PLAN HMO
WI30105800Medicaid
10637OtherDEAN HEALTH PLAN HMO