Provider Demographics
NPI:1922161728
Name:SHEBOYGAN INTERNAL MEDICINE ASSOCIATES, SC
Entity Type:Organization
Organization Name:SHEBOYGAN INTERNAL MEDICINE ASSOCIATES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOUANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-452-6000
Mailing Address - Street 1:2920 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1944
Mailing Address - Country:US
Mailing Address - Phone:920-452-6000
Mailing Address - Fax:920-803-2990
Practice Address - Street 1:2920 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1944
Practice Address - Country:US
Practice Address - Phone:920-452-6000
Practice Address - Fax:920-803-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32872000Medicaid
WI32872000Medicaid