Provider Demographics
NPI:1740343359
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 EMPLOYEE
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:920-623-9989
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:920-623-9989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24077208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0020103002Medicaid
MTDB7643OtherRAILROAD MEDICARE
WI30673100Medicaid
WI=========OtherDEAN CARE
WI=========OtherWEA TRUST-ALLIANCE
MTDB7643OtherRAILROAD MEDICARE
WI=========OtherHEALTH INSURANCE RISK PRO
WI=========WOtherUNITY
ID0020103002Medicaid
WI30673100Medicaid
WI=========OtherWISCONSIN PHYSICIAN SERVI
WI=========OtherTIME
WI=========OtherPHYSICIANS PLUS INSURANCE
WI=========OtherHEALTH INSURANCE RISK PRO