Provider Demographics
NPI:1023094885
Name:KERMGARD, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:KERMGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3423
Mailing Address - Country:US
Mailing Address - Phone:920-926-8492
Mailing Address - Fax:920-926-8903
Practice Address - Street 1:145 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3423
Practice Address - Country:US
Practice Address - Phone:920-926-8492
Practice Address - Fax:920-926-8903
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36091592207PE0004X
WI34936020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36091592Medicaid
WI31984300Medicaid
WI1023094885OtherBLUE SHIELD
WI1023094885OtherBLUE SHIELD
B23911Medicare UPIN
WI007101473Medicare PIN
WI31984300Medicaid
ILB23911Medicare UPIN