Provider Demographics
NPI:1689626632
Name:ROSELAAR, SIMON EDWIN (MD)
Entity Type:Individual
Prefix:MR
First Name:SIMON
Middle Name:EDWIN
Last Name:ROSELAAR
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:BIN 88040
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53288-0040
Mailing Address - Country:US
Mailing Address - Phone:920-886-9380
Mailing Address - Fax:920-886-9381
Practice Address - Street 1:5045 W GRANDE MARKET DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8517
Practice Address - Country:US
Practice Address - Phone:920-886-9380
Practice Address - Fax:920-886-9381
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40974-020207R00000X, 207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32543500Medicaid
WI0017Medicare ID - Type Unspecified
WI32543500Medicaid