Provider Demographics
NPI:1669437778
Name:SKOCHELAK, SUSAN E (MD MPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:SKOCHELAK
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8007 EXCELSIOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717
Mailing Address - Country:US
Mailing Address - Phone:608-829-5247
Mailing Address - Fax:
Practice Address - Street 1:621 SCIENCE DRIVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711
Practice Address - Country:US
Practice Address - Phone:608-265-8400
Practice Address - Fax:608-265-8410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28083207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30770000Medicaid
WI30770000Medicaid
047C15875Medicare ID - Type Unspecified