Basic Information
| Provider Information | |||||||||
| NPI: | 1316951213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOX VALLEY DERMATOLOGY SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3420 JACKSON ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549018144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204262211 | ||||||||
| FaxNumber: | 9204262231 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 S WASHBURN ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202321130 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LENZ | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9204262211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 42905020 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 34045300 | 05 | WI | MEDICAID |