Provider Demographics
NPI:1639164908
Name:KANE, ROXANNE J (MD)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:J
Last Name:KANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:J
Other - Last Name:SUSLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3040 N 117TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4107
Mailing Address - Country:US
Mailing Address - Phone:414-479-9990
Mailing Address - Fax:414-479-0230
Practice Address - Street 1:3040 N 117TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4107
Practice Address - Country:US
Practice Address - Phone:414-479-9990
Practice Address - Fax:414-479-0230
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36066208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32204200Medicaid
WI32204200Medicaid
WI01750Medicare ID - Type Unspecified