Provider Demographics
NPI:1164478475
Name:MARY M. RAJALA, M.D., S.C.
Entity Type:Organization
Organization Name:MARY M. RAJALA, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAJALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-498-4200
Mailing Address - Street 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4257
Mailing Address - Country:US
Mailing Address - Phone:262-787-4026
Mailing Address - Fax:262-782-6040
Practice Address - Street 1:855 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1241
Practice Address - Country:US
Practice Address - Phone:920-846-3444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31996300Medicaid
WI07592Medicare ID - Type UnspecifiedMEDICARE NUMBER
WI31996300Medicaid