1265720122 NPI number — MS. ROXANNE MARIE BAETHKE P.T.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265720122 NPI number — MS. ROXANNE MARIE BAETHKE P.T.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAETHKE
Provider First Name:
ROXANNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265720122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 MONTGOMERY ST
Provider Second Line Business Mailing Address:
TEAM REHAB LC
Provider Business Mailing Address City Name:
DECORAH
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-382-4770
Provider Business Mailing Address Fax Number:
563-382-4785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 MONTGOMERY ST
Provider Second Line Business Practice Location Address:
TEAM REHAB LC
Provider Business Practice Location Address City Name:
DECORAH
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-382-4770
Provider Business Practice Location Address Fax Number:
563-382-4785
Provider Enumeration Date:
07/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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