Provider Demographics
NPI:1386832228
Name:MARIANO L. ROSALES JR., M.D. S.C.
Entity Type:Organization
Organization Name:MARIANO L. ROSALES JR., M.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANO
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSALES JR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-324-3559
Mailing Address - Street 1:600 FERN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1018
Mailing Address - Country:US
Mailing Address - Phone:920-324-3559
Mailing Address - Fax:920-324-0258
Practice Address - Street 1:600 FERN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1018
Practice Address - Country:US
Practice Address - Phone:920-324-3559
Practice Address - Fax:920-324-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2190120261Q00000X
WI2190620261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
B56135Medicare UPIN