Basic Information
| Provider Information | |||||||||
| NPI: | 1194793273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEROLD | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHMIDT | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 19070 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543079070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1411 N TAYLOR DR | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530813043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
| FaxNumber: | 9204964705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 40654020 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32500800 | 05 | WI | MEDICAID |