Physician Compare National (NPI:1053578682)

HEALTHCARE PROVIDER: TODD ALAN DERKSEN DPM

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1053578682
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	5496821068
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20080904000627
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	DERKSEN
	Individual professional last name
Provider First Name	TODD
	Individual professional first name
Provider Middle Name	A
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OTHER
	Individual professional's medical school
Graduation Year	2005
	Individual professional's medical school graduation year
Primary Specialty	PODIATRY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	VALLEY ORTHOPEDIC CLINIC SC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	5294725602
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	10
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	2105 E ENTERPRISE AVE
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 111
	Group Practice or individual's line 2 address
City	APPLETON
	Group Practice or individual's city
State	WI
	Group Practice or individual's state
Zip Code	549137862
	Group Practice or individual's zip code (9 digits when available)
Phone Number	9207316611
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	520160
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	THEDACARE REGIONAL MEDICAL CENTER - APPLETON INC
	Legal business name of hospital where individual professional provides service 1
Professional Accepts Medicare Assignment	Y