Basic Information
| Provider Information | |||||||||
| NPI: | 1548298789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2845 GREENBRIER RD STE 240 | ||||||||
| Address2: | PO BOX 8900 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543088900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888280 | ||||||||
| FaxNumber: | 9202888285 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 GREENBRIER RD STE 240 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888280 | ||||||||
| FaxNumber: | 9202888285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 08/29/2008 | ||||||||
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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 | 208800000X | 37353 | WI | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3402100631 | 01 | MI | BCBS | OTHER | 32215300 | 05 | WI | MEDICAID | 340015990 | 01 | WI | RAILROAD | OTHER | 104236924 | 05 | MI | MEDICAID | 104386144 | 05 | MI | MEDICAID |