Provider Demographics
NPI:1326038811
Name:LALICH, ROGER A (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:LALICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 AMERICAN AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-549-2229
Mailing Address - Fax:262-549-1657
Practice Address - Street 1:721 AMERICAN AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-549-2229
Practice Address - Fax:262-549-1657
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21566207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30010700Medicaid
WIE46168Medicare UPIN
WI687400002Medicare ID - Type Unspecified