Healthcare Provider Details

I. General information

NPI: 1942229331
Provider Name (Legal Business Name): SUSAN K. KINAST-PORTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N2950 STATE ROAD 67
LAKE GENEVA WI
53147-2655
US

IV. Provider business mailing address

N2950 STATE ROAD 67
LAKE GENEVA WI
53147-2655
US

V. Phone/Fax

Practice location:
  • Phone: 262-245-0535
  • Fax: 262-245-2227
Mailing address:
  • Phone: 262-245-0535
  • Fax: 262-245-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number23108-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23108-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: