Provider Demographics
NPI:1730238890
Name:KAGEN DERMATOLOGY CLINIC SC
Entity type:Organization
Organization Name:KAGEN DERMATOLOGY CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:KAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-733-5138
Mailing Address - Street 1:100 W LAWRENCE ST
Mailing Address - Street 2:SUITE 409
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5773
Mailing Address - Country:US
Mailing Address - Phone:920-733-5138
Mailing Address - Fax:920-733-3759
Practice Address - Street 1:100 W LAWRENCE ST
Practice Address - Street 2:SUITE 409
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5773
Practice Address - Country:US
Practice Address - Phone:920-733-5138
Practice Address - Fax:920-733-3759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24388174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty