Provider Demographics
NPI:1316945512
Name:GARRISON, KENNETH JOE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOE
Last Name:GARRISON
Suffix:
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:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0189
Mailing Address - Country:US
Mailing Address - Phone:715-468-2711
Mailing Address - Fax:715-468-2727
Practice Address - Street 1:105 4TH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-0189
Practice Address - Country:US
Practice Address - Phone:715-468-2711
Practice Address - Fax:715-468-2727
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45490208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34380700Medicaid
MN266R9GAOtherCOMPREHENSIVE CARE SVS
WI34380700Medicaid
WI166001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER