Provider Demographics
NPI:1144298878
Name:LISBERG, KENNETH J (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:LISBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2920 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1944
Mailing Address - Country:US
Mailing Address - Phone:920-452-4911
Mailing Address - Fax:920-458-3163
Practice Address - Street 1:2920 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1944
Practice Address - Country:US
Practice Address - Phone:920-452-4911
Practice Address - Fax:920-458-3163
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI18543208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30309500Medicaid
WIB54619Medicare UPIN
WI30309500Medicaid