MEDICARE: SUSAN H KRECKMAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	39356	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376527002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN H KRECKMAN MD

Provider Business Mailing Address
First Line	:	2817 NEW PINERY RD.
Second Line	:	DIVINE SAVIOR HEALTHCARE, INC.
City	:	PORTAGE
State	:	WI
Zip	:	53901-0387
Country	:	US
Telephone Number	:	608-745-4598
Fax Number	:	608-745-6242

Provider Business Practice Location Address
First Line	:	2817 NEW PINERY RD.
Second Line	:	DIVINE SAVIOR HEALTHCARE, INC.
City	:	PORTAGE
State	:	WI
Zip	:	53901-0387
Country	:	US
Telephone Number	:	608-745-4598
Fax Number	:	608-745-6242

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	10/14/2011

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