Basic Information
| Provider Information | |||||||||
| NPI: | 1134114200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGUIRE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | KELLOGG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3123 SHORE DR | ||||||||
| Address2: | SUITE #102 | ||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157322299 | ||||||||
| FaxNumber: | 7157322419 | ||||||||
| Practice Location | |||||||||
| Address1: | 3123 SHORE DR | ||||||||
| Address2: | SUITE #102 | ||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157322299 | ||||||||
| FaxNumber: | 7157322419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 11/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25995 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110047469 | 01 | WI | MEDICARE RAILROAD | OTHER | 30682900 | 05 | WI | MEDICAID |