Provider Demographics
NPI:1659489789
Name:PESCHKE, SCOTT R (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:R
Last Name:PESCHKE
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 1:2600 KILEY WAY
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-5020
Mailing Address - Country:US
Mailing Address - Phone:920-449-7000
Mailing Address - Fax:
Practice Address - Street 1:2600 KILEY WAY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-5020
Practice Address - Country:US
Practice Address - Phone:920-449-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30647600Medicaid
WI30647600Medicaid
AP2140832OtherDEA NUMBER
B55692Medicare UPIN