Healthcare Provider Details

I. General information

NPI: 1104386911
Provider Name (Legal Business Name): PHILIP THOMAS SKUMMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

IV. Provider business mailing address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-6084
  • Fax:
Mailing address:
  • Phone: 920-433-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2026048564
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number76025-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: