1659390557 NPI number — DR. ROGER A PELLMANN M.D.

Table of content: DR. ROGER A PELLMANN M.D. (NPI 1659390557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659390557 NPI number — DR. ROGER A PELLMANN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLMANN
Provider First Name:
ROGER
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1659390557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6400 INDUSTRIAL LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53129-2452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-423-4100
Provider Business Mailing Address Fax Number:
414-423-4134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W178N9912 RIVERCREST DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53022-4645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-255-4500
Provider Business Practice Location Address Fax Number:
262-255-6500
Provider Enumeration Date:
07/19/2006

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: 2085R0202X , with the licence number:  25006020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X , with the licence number: 25006020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 30494100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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