Provider Demographics
NPI:1306953419
Name:THUR, JEAN RUTH (DO)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:RUTH
Last Name:THUR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:R
Other - Last Name:GOGOLIN
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:920-303-8700
Mailing Address - Fax:
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904
Practice Address - Country:US
Practice Address - Phone:920-303-8700
Practice Address - Fax:920-456-5831
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36090947208000000X
WI37755208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30069500Medicaid