Provider Demographics
NPI:1124030499
Name:KROLL, MARK R (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:KROLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 28900
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54324-0900
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:920-405-5388
Practice Address - Street 1:2253 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4706
Practice Address - Country:US
Practice Address - Phone:920-327-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30436-21207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30049600Medicaid
WI30049600Medicaid
WI07010-0262Medicare PIN