Provider Demographics
NPI:1962636043
Name:PORTSCHY, PAMELA R (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:R
Last Name:PORTSCHY
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 1:2414 KOHLER MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3129
Mailing Address - Country:US
Mailing Address - Phone:920-457-4461
Mailing Address - Fax:
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-459-1160
Practice Address - Fax:920-459-1414
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70813208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100022813Medicaid