Provider Demographics
NPI:1326090697
Name:ERDMAN, RICHARD L (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:ERDMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2638
Mailing Address - Country:US
Mailing Address - Phone:920-246-0172
Mailing Address - Fax:
Practice Address - Street 1:725 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3500
Practice Address - Country:US
Practice Address - Phone:920-433-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24509-020207P00000X
WI24509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI930121595OtherMEDICARE RAILROAD
WI30717200Medicaid
MI104462228Medicaid
WIB84826Medicare UPIN
WI002150272Medicare Oscar/Certification
WI072900061Medicare Oscar/Certification
WI002717130Medicare ID - Type Unspecified
WIP01020920Medicare Oscar/Certification
WIP01006551Medicare Oscar/Certification
MI104462228Medicaid