Healthcare Provider Details

I. General information

NPI: 1063741098
Provider Name (Legal Business Name): DR KEVIN S MYERS MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2009
Last Update Date: 12/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 N 25TH ST
SHEBOYGAN WI
53081-3108
US

IV. Provider business mailing address

1440 N 25TH ST
SHEBOYGAN WI
53081-3108
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-9100
  • Fax: 920-457-1461
Mailing address:
  • Phone: 920-457-9100
  • Fax: 920-457-1461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN S MYERS
Title or Position: MD
Credential: MD
Phone: 920-457-9100