Provider Demographics
NPI:1740364132
Name:JEANNE S. VEDDER M.D SC
Entity type:Organization
Organization Name:JEANNE S. VEDDER M.D SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:VEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-657-6577
Mailing Address - Street 1:1400-75 STREET
Mailing Address - Street 2:SUITE 4
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1522
Mailing Address - Country:US
Mailing Address - Phone:262-657-6577
Mailing Address - Fax:262-657-7844
Practice Address - Street 1:1400-75 STREET
Practice Address - Street 2:SUITE 4
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1522
Practice Address - Country:US
Practice Address - Phone:262-657-6577
Practice Address - Fax:262-657-7844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1000086OtherUNITED HEALTHCARE
WI1532113OtherUNITED MINE WORKERS
WI396608943E04OtherBLUE CROSS BLUE SHIELD
WI31564000Medicaid