Basic Information
| Provider Information | |||||||||
| NPI: | 1588737456 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNETH J GARRISON, MD, SC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P O BOX 189 | ||||||||
| Address2: | 105 4TH AVE | ||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154682711 | ||||||||
| FaxNumber: | 7154682727 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154682711 | ||||||||
| FaxNumber: | 7154682727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARRISON | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | JOE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7158223654 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 45490 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 26097135226 | 01 | MN | PREFERRED ONE | OTHER | 1701193 | 01 | WI | SELECTCARE | OTHER | 108390 | 01 | MN | HEALTH PARTNERS | OTHER | 5999172200 | 01 | MN | MN MEDICAID | OTHER | 266R0GA | 01 | MN | COMPREHENSIVE CARE SVS | OTHER | P00013163 | 01 | WI | RAILROAD MEDICARE | OTHER | 1701194 | 01 | WI | SELECTCARE | OTHER | 34380700 | 05 | WI | MEDICAID |