Individual
BETH COLLISTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
360 S MOUNTIN DR, MAYVILLE, WI 53050-1498
(920) 387-7500
Mailing address
420 E DIVISION ST, FOND DU LAC, WI 54935-4560
(920) 926-8340
(920) 926-8370
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
33156
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080076572
RAILROAD MEDICARE
WI
05
—
31826800
—
WI
Enumeration date
11/02/2005
Last updated
11/10/2020
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