Healthcare Provider Details

I. General information

NPI: 1023094885
Provider Name (Legal Business Name): MARK S KERMGARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N MAIN ST
FOND DU LAC WI
54935-3423
US

IV. Provider business mailing address

145 N MAIN ST
FOND DU LAC WI
54935-3423
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-8492
  • Fax: 920-926-8903
Mailing address:
  • Phone: 920-926-8492
  • Fax: 920-926-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34936020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number36091592
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: