Provider Demographics
NPI:1679655377
Name:SHEBOYGAN WOMEN'S HEALTH, S.C.
Entity type:Organization
Organization Name:SHEBOYGAN WOMEN'S HEALTH, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-458-4419
Mailing Address - Street 1:1621 N TAYLOR DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1992
Mailing Address - Country:US
Mailing Address - Phone:920-458-4419
Mailing Address - Fax:920-458-7516
Practice Address - Street 1:1621 N TAYLOR DR STE 300
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1992
Practice Address - Country:US
Practice Address - Phone:920-458-4419
Practice Address - Fax:920-458-7516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI435890207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32882800Medicaid