MEDICARE: ROCK RIVER FOOT & ANKLE CLINIC, 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	213ES0103X	Foot & Ankle Surgery Podiatrist

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	:	1649313578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCK RIVER FOOT & ANKLE CLINIC, SC

Provider Business Mailing Address
First Line	:	101 OAKRIDGE CT
Second Line	:	SUITE A
City	:	WATERTOWN
State	:	WI
Zip	:	53094-4100
Country	:	US
Telephone Number	:	920-261-9610
Fax Number	:	920-261-9671

Provider Business Practice Location Address
First Line	:	1461 W MAIN ST
Second Line	:
City	:	WHITEWATER
State	:	WI
Zip	:	53190-1568
Country	:	US
Telephone Number	:	920-563-2136
Fax Number	:	920-563-3673

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VICTOR STEPHEN SODERSTROM
Credential	:	D.P.M.
Telephone Number	:	920-261-9610

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	11/01/2007

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