Healthcare Provider Details

I. General information

NPI: 1376527002
Provider Name (Legal Business Name): SUSAN H KRECKMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 NEW PINERY RD. DIVINE SAVIOR HEALTHCARE, INC.
PORTAGE WI
53901-0387
US

IV. Provider business mailing address

2817 NEW PINERY RD. DIVINE SAVIOR HEALTHCARE, INC.
PORTAGE WI
53901-0387
US

V. Phone/Fax

Practice location:
  • Phone: 608-745-4598
  • Fax: 608-745-6242
Mailing address:
  • Phone: 608-745-4598
  • Fax: 608-745-6242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39356
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: