Provider Demographics
NPI:1073100178
Name:REBEDEW, TY
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:REBEDEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1621
Mailing Address - Country:US
Mailing Address - Phone:920-361-3515
Mailing Address - Fax:920-361-2733
Practice Address - Street 1:147 N STATE ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1621
Practice Address - Country:US
Practice Address - Phone:920-361-3515
Practice Address - Fax:920-361-2733
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3306-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5588-12Medicaid