Healthcare Provider Details

I. General information

NPI: 1003866864
Provider Name (Legal Business Name): MARK T. ROVICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 N WESTHILL BLVD
APPLETON WI
54914-5715
US

IV. Provider business mailing address

444 N WESTHILL BLVD
APPLETON WI
54914-5715
US

V. Phone/Fax

Practice location:
  • Phone: 920-750-7000
  • Fax: 920-364-2451
Mailing address:
  • Phone: 920-750-7000
  • Fax: 920-364-2451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number52152-21
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number44254
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1003866864
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: