Provider Demographics
NPI:1689871451
Name:ROCKY MOUNTAIN UROLOGY,LLC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN UROLOGY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ERVIN
Authorized Official - Last Name:KUGLITSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-623-9970
Mailing Address - Street 1:1511 PARK AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-2401
Mailing Address - Country:US
Mailing Address - Phone:920-623-9970
Mailing Address - Fax:920-623-9970
Practice Address - Street 1:1511 PARK AVE
Practice Address - Street 2:SUITE F
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-2401
Practice Address - Country:US
Practice Address - Phone:920-623-9970
Practice Address - Fax:920-623-9970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT70892088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0020103002Medicaid
ID8N223OtherBC IDAHO
ID000010154126OtherREGENCY BLUE SHIELD OF ID
MTDB7643OtherRAILROAD MEDICARE
MT0081226Medicaid
WI30673100Medicaid
WI=========012OtherANTHEM BC WISCONSIN
WI=========OtherSTATE FARM INSURANCE
ID8N223OtherBC IDAHO
WI=========OtherHUMANA GOLD
WI30673100Medicaid