Healthcare Provider Details

I. General information

NPI: 1487958765
Provider Name (Legal Business Name): FOUNTAIN CITY SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2010
Last Update Date: 12/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WISCONSIN AMERICAN DR
FOND DU LAC WI
54937-2999
US

IV. Provider business mailing address

210 WISCONSIN AMERICAN DR
FOND DU LAC WI
54937-2999
US

V. Phone/Fax

Practice location:
  • Phone: 920-907-7400
  • Fax: 920-907-7401
Mailing address:
  • Phone: 920-904-7400
  • Fax: 920-907-7401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number23895
License Number StateWI

VIII. Authorized Official

Name: DR. DONALD F VAN BEEK
Title or Position: GENERAL SURGEON
Credential: M.D.
Phone: 920-907-7400