1396776589 NPI number — MR. ROGER A HANDTKE DO

Table of content: MR. ROGER A HANDTKE DO (NPI 1396776589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396776589 NPI number — MR. ROGER A HANDTKE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANDTKE
Provider First Name:
ROGER
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1396776589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13380 W TREPANIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYWARD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54843-2186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-638-5100
Provider Business Mailing Address Fax Number:
715-634-6107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ESSENTIA HEALTH SPOONER CLINIC
Provider Second Line Business Practice Location Address:
1180 CHANDLER DRIVE
Provider Business Practice Location Address City Name:
SPOONER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-635-2151
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2006

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: 207Q00000X , with the licence number:  02001222A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 63316 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100209300 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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