Basic Information
| Provider Information | |||||||||
| NPI: | 1760591036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KARI | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KREUL | ||||||||
| OtherFirstName: | KARI | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 218 | ||||||||
| Address2: | 2600 65TH AVENUE | ||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540203024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152942111 | ||||||||
| FaxNumber: | 7152942111 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 65TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540203024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152942111 | ||||||||
| FaxNumber: | 7152945758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44372 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 40815 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 44372 | 01 | WI | MEDICAL LICENSE | OTHER | 34199600 | 05 | WI | MEDICAID |