Provider Demographics
NPI:1669695284
Name:FOX VALLEY PLASTIC SURGERY, S.C.
Entity type:Organization
Organization Name:FOX VALLEY PLASTIC SURGERY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-233-1540
Mailing Address - Street 1:2400 WITZEL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8369
Mailing Address - Country:US
Mailing Address - Phone:920-233-1540
Mailing Address - Fax:920-651-6951
Practice Address - Street 1:2400 WITZEL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-8369
Practice Address - Country:US
Practice Address - Phone:920-233-1540
Practice Address - Fax:920-651-6951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIF46228Medicare UPIN
WIA79024Medicare UPIN