Basic Information
Provider Information | |||||||||
NPI: | 1790777621 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KROHN CLINIC LTD. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 610 W ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | BLACK RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 546159010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152844311 | ||||||||
FaxNumber: | 7152842568 | ||||||||
Practice Location | |||||||||
Address1: | 610 W ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | BLACK RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 546159010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152844311 | ||||||||
FaxNumber: | 7152840475 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2005 | ||||||||
LastUpdateDate: | 08/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SALSMAN | ||||||||
AuthorizedOfficialFirstName: | SANDRA | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7152844311 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0580630001 | 01 | WI | MEDICARE - DMEPOS | OTHER | 32726800 | 05 | WI |   | MEDICAID |