Provider Demographics
NPI:1194793273
Name:HEROLD, SUZANNE S (MD)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:S
Last Name:HEROLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:MARIE
Other - Last Name:SCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1411 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3043
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-496-4705
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40654020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32500800Medicaid
WI000660245Medicare ID - Type Unspecified
WI32500800Medicaid