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General NPI Number Information
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NPI Number | 1487703880
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Entity Type | Organization
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Legal Business Name | WISCONSIN INSTITUTE OF PLASTIC SURGERY SC
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Dates
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Enumeration Date | 01/09/2007
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Last Update Date | 10/21/2021
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Provider Practice Location Address
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Address Line | 2700 E ENTERPRISE AVE STE A
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City | APPLETON
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State | WI
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Zip | 54913-7656
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Country | US
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Telephone | 920-965-1234
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Fax | 920-965-1232
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Provider Business Mailing Address
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Address Line | 2200 DICKINSON RD STE 17B
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City | DE PERE
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State | WI
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Zip | 54115-4056
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Country | US
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Telephone | 920-965-1234
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Fax | 920-965-1232
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | WENDY J JUSTUS
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Credential |
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Telephone | 920-965-1234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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