Provider Demographics
NPI:1942229331
Name:KINAST-PORTER, SUSAN K (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:KINAST-PORTER
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:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:262-245-0535
Mailing Address - Fax:262-245-2227
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-0535
Practice Address - Fax:262-245-2227
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23108-020208M00000X
WI23108-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI61018OtherDEAN HEALTH INSURANCE
WIKINASSUSOtherMERCYCARE INSURANCE
WI30467900Medicaid
WI1942229331OtherBCBSWI
WI1942229331Medicaid
WI1942229331Medicaid
WI30467900Medicaid
WI61018OtherDEAN HEALTH INSURANCE
WI1942229331OtherBCBSWI
WI543400513Medicare PIN