Provider Demographics
NPI:1821199449
Name:HANSEN, ROLF H (DPM)
Entity Type:Individual
Prefix:
First Name:ROLF
Middle Name:H
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3116
Mailing Address - Country:US
Mailing Address - Phone:920-887-3102
Mailing Address - Fax:920-855-8790
Practice Address - Street 1:130 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3116
Practice Address - Country:US
Practice Address - Phone:920-887-3102
Practice Address - Fax:920-855-8790
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI865025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1821199449Medicaid
WIP01442907Medicare PIN
K400129398Medicare PIN
4831620001Medicare PIN
K400129398Medicare PIN
000082081Medicare PIN
4831620001Medicare PIN