Provider Demographics
NPI:1043461460
Name:FOX VALLEY GASTROENTEROLOGY, S.C.
Entity type:Organization
Organization Name:FOX VALLEY GASTROENTEROLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GEALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-731-9700
Mailing Address - Street 1:900 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3487
Mailing Address - Country:US
Mailing Address - Phone:920-731-9700
Mailing Address - Fax:920-731-2234
Practice Address - Street 1:900 E GRANT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3487
Practice Address - Country:US
Practice Address - Phone:920-731-9700
Practice Address - Fax:920-731-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25010174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32668300Medicaid
WIB53016Medicare UPIN
WI45010Medicare PIN