Provider Demographics
NPI:1588737456
Name:KENNETH J GARRISON, MD, SC
Entity type:Organization
Organization Name:KENNETH J GARRISON, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:715-822-3654
Mailing Address - Street 1:P O BOX 189
Mailing Address - Street 2:105 4TH AVE
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45490208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN26097135226OtherPREFERRED ONE
WI1701193OtherSELECTCARE
MN108390OtherHEALTH PARTNERS
MN5999172200OtherMN MEDICAID
MN266R0GAOtherCOMPREHENSIVE CARE SVS
WIP00013163OtherRAILROAD MEDICARE
WI1701194OtherSELECTCARE
WI34380700Medicaid
WI1701194OtherSELECTCARE
MN5999172200OtherMN MEDICAID
WI66001Medicare ID - Type UnspecifiedGROUP