Provider Demographics
NPI:1023204286
Name:BEAVER DAM FOOT & ANKLE CENTER, INC.
Entity Type:Organization
Organization Name:BEAVER DAM FOOT & ANKLE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLF
Authorized Official - Middle Name:HARALD
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-885-6434
Mailing Address - Street 1:301 S ROOSEVELT DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2439
Mailing Address - Country:US
Mailing Address - Phone:920-885-6434
Mailing Address - Fax:920-885-2640
Practice Address - Street 1:301 S ROOSEVELT DR
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2439
Practice Address - Country:US
Practice Address - Phone:920-885-6434
Practice Address - Fax:920-885-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI865213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI565892OtherDEAN CARE
WI43266400Medicaid
WI565892OtherDEAN CARE
WIU45179Medicare UPIN