Healthcare Provider Details

I. General information

NPI: 1477819902
Provider Name (Legal Business Name): SHEBOYGAN PHYSICIANS GROUP, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 10/11/2022
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 SUPERIOR AVE
SHEBOYGAN WI
53081-1944
US

IV. Provider business mailing address

2920 SUPERIOR AVE
SHEBOYGAN WI
53081-1944
US

V. Phone/Fax

Practice location:
  • Phone: 920-452-6000
  • Fax: 920-803-2990
Mailing address:
  • Phone: 920-452-6000
  • Fax: 920-803-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLEY RENZELMANN
Title or Position: ADMINISTRATOR
Credential:
Phone: 920-452-6000