Provider Demographics
NPI:1487703880
Name:WISCONSIN INSTITUTE OF PLASTIC SURGERY SC
Entity type:Organization
Organization Name:WISCONSIN INSTITUTE OF PLASTIC SURGERY SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JUSTUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-965-1234
Mailing Address - Street 1:2200 DICKINSON RD STE 17B
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-4056
Mailing Address - Country:US
Mailing Address - Phone:920-965-1234
Mailing Address - Fax:920-965-1232
Practice Address - Street 1:2700 E ENTERPRISE AVE STE A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7656
Practice Address - Country:US
Practice Address - Phone:920-965-1234
Practice Address - Fax:920-965-1232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3677500Medicaid
WI3677500Medicaid