Provider Demographics
NPI:1285694141
Name:FAIRCHILD, RALPH B III (MD)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:B
Last Name:FAIRCHILD
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 PINE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-7803
Mailing Address - Country:US
Mailing Address - Phone:715-847-2022
Mailing Address - Fax:
Practice Address - Street 1:2400 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-7803
Practice Address - Country:US
Practice Address - Phone:715-847-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN517032086S0129X, 2086S0129X, 208600000X, 2086S0102X, 2086S0102X, 2086S0129X
WI425112086S0129X, 2086S0129X, 2086S0129X
ORMD1511652086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34003000Medicaid
WIK400235515OtherMEDICARE
WI34003000Medicaid