Basic Information
| Provider Information | |||||||||
| NPI: | 1306855705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 323 S 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542351401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207460510 | ||||||||
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| Practice Location | |||||||||
| Address1: | 323 S 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542351401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207460510 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 46270 | WI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 34482200 | 05 | WI | MEDICAID |