Premier Surgical of Wisconsin SC

Primary specialty

Surgery PhysicianTaxonomy code 208600000X

License

19677020 Issued in WI

Legal business name

PREMIER SURGICAL OF WISCONSIN SC

Practice address

940 Maritime Dr
Ste 4
Maintowoc, WI 54220-2960

Phone

(920) 686-7900

Fax

(920) 686-7984

NPI assigned

Sep 20, 2006

Last updated

Aug 8, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Kimberly A Ridl, MD

Title

President

Phone

(920) 686-7900

Specialties & licenses 1

Addresses

Other identifiers 2

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Dennis Frederick Zagrodnik II, M.D.

  • Surgery Physician
  • Summit, WI
  • NPI 1538155569
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1691452800000",
    "number": "1679671408",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "940 MARITIME DR",
            "address_2": "STE 4",
            "city": "MANITOWOC",
            "state": "WI",
            "postal_code": "542202960",
            "telephone_number": "920-686-7900",
            "fax_number": "920-686-7984"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "940 MARITIME DR",
            "address_2": "STE 4",
            "city": "MAINTOWOC",
            "state": "WI",
            "postal_code": "542202960",
            "telephone_number": "920-686-7900",
            "fax_number": "920-686-7984"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIER SURGICAL OF WISCONSIN SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-20",
        "last_updated": "2023-08-08",
        "certification_date": "2023-08-08",
        "status": "A",
        "authorized_official_last_name": "RIDL",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "920-686-7900",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "WI",
            "license": "19677020",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31123900",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "DG9827",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.