Provider Demographics
NPI:1659390557
Name:PELLMANN, ROGER A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:PELLMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4100
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:W178N9912 RIVERCREST DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-4645
Practice Address - Country:US
Practice Address - Phone:262-255-4500
Practice Address - Fax:262-255-6500
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI250060202085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30494100Medicaid
WI000167205Medicare PIN