Basic Information
| Provider Information | |||||||||
| NPI: | 1821123019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3232 N BALLARD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549118804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207499668 | ||||||||
| FaxNumber: | 9207345307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3925 N GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549137863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207491171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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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 | 207RH0003X | 32771 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0002X | 32771 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31760000 | 05 | WI | MEDICAID |