Healthcare Provider Details

I. General information

NPI: 1215994363
Provider Name (Legal Business Name): KENNETH G CONDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date: 10/14/2020
Reactivation Date: 07/12/2023

III. Provider practice location address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5511
  • Fax:
Mailing address:
  • Phone: 715-387-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number24143
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: