Provider Demographics
NPI:1477638955
Name:ELLWEIN, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:ELLWEIN
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 1:700 WEST AVE S
Mailing Address - Street 2:PHYSICIAN SERVICES
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4783
Mailing Address - Country:US
Mailing Address - Phone:608-392-4156
Mailing Address - Fax:608-392-9898
Practice Address - Street 1:800 WEST AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:LACROSSE
Practice Address - State:WI
Practice Address - Zip Code:56401
Practice Address - Country:US
Practice Address - Phone:608-782-9760
Practice Address - Fax:608-392-9898
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19976207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30790600Medicaid
B52621Medicare UPIN