Provider Demographics
NPI:1679671408
Name:PREMIER SURGICAL OF WISCONSIN SC
Entity type:Organization
Organization Name:PREMIER SURGICAL OF WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIDL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-686-7900
Mailing Address - Street 1:940 MARITIME DR
Mailing Address - Street 2:STE 4
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2960
Mailing Address - Country:US
Mailing Address - Phone:920-686-7900
Mailing Address - Fax:920-686-7984
Practice Address - Street 1:940 MARITIME DR
Practice Address - Street 2:STE 4
Practice Address - City:MAINTOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2960
Practice Address - Country:US
Practice Address - Phone:920-686-7900
Practice Address - Fax:920-686-7984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19677020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIDG9827OtherRAILROAD MEDICARE
WI31123900Medicaid
WI=========012OtherANTHEM
WIDG9827OtherRAILROAD MEDICARE