MEDICARE: WISCONSIN INSTITUTE OF PLASTIC SURGERY SC

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	207W00000X	Ophthalmology Physician
2	208200000X	Plastic Surgery Physician

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	:	1487703880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN INSTITUTE OF PLASTIC SURGERY SC

Provider Business Mailing Address
First Line	:	2200 DICKINSON RD STE 17B
Second Line	:
City	:	DE PERE
State	:	WI
Zip	:	54115-4056
Country	:	US
Telephone Number	:	920-965-1234
Fax Number	:	920-965-1232

Provider Business Practice Location Address
First Line	:	2700 E ENTERPRISE AVE STE A
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54913-7656
Country	:	US
Telephone Number	:	920-965-1234
Fax Number	:	920-965-1232

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	WENDY J JUSTUS
Credential	:
Telephone Number	:	920-965-1234

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	10/21/2021

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