1588737456 NPI number — KENNETH J GARRISON, MD, SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588737456 NPI number — KENNETH J GARRISON, MD, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH J GARRISON, MD, SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588737456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 189
Provider Second Line Business Mailing Address:
105 4TH AVE
Provider Business Mailing Address City Name:
SHELL LAKE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54871-0189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-468-2711
Provider Business Mailing Address Fax Number:
715-468-2727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELL LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54871-0189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-468-2711
Provider Business Practice Location Address Fax Number:
715-468-2727
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARRISON
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
JOE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
715-822-3654

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  45490 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 26097135226 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1701193 . This is a "SELECTCARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 108390 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5999172200 . This is a "MN MEDICAID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 266R0GA . This is a "COMPREHENSIVE CARE SVS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00013163 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1701194 . This is a "SELECTCARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 34380700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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