Healthcare Provider Details

I. General information

NPI: 1689626632
Provider Name (Legal Business Name): SIMON EDWIN ROSELAAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5045 W GRANDE MARKET DR
APPLETON WI
54913-8517
US

IV. Provider business mailing address

BIN 88040
MILWAUKEE WI
53288-0040
US

V. Phone/Fax

Practice location:
  • Phone: 920-886-9380
  • Fax: 920-886-9381
Mailing address:
  • Phone: 920-886-9380
  • Fax: 920-886-9381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40974-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number40974-020
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number40974-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: