Provider Demographics
NPI:1972629145
Name:SHEBOYGAN SURGICAL ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:SHEBOYGAN SURGICAL ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LOUANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-452-0446
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:920-452-0446
Mailing Address - Fax:920-458-3163
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:920-452-0446
Practice Address - Fax:920-458-3163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32664000Medicaid
WIH81828Medicare UPIN
WIB54619Medicare UPIN
WI32664000Medicaid
WIG32450Medicare UPIN