Provider Demographics
NPI:1063741098
Name:DR KEVIN S MYERS MDSC
Entity type:Organization
Organization Name:DR KEVIN S MYERS MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-457-9100
Mailing Address - Street 1:1440 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3108
Mailing Address - Country:US
Mailing Address - Phone:920-457-9100
Mailing Address - Fax:920-457-1461
Practice Address - Street 1:1440 N 25TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3108
Practice Address - Country:US
Practice Address - Phone:920-457-9100
Practice Address - Fax:920-457-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000060048Medicare PIN
WIB55290Medicare UPIN