Healthcare Provider Details

I. General information

NPI: 1689871451
Provider Name (Legal Business Name): ROCKY MOUNTAIN UROLOGY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 PARK AVE SUITE F
COLUMBUS WI
53925-2401
US

IV. Provider business mailing address

1511 PARK AVE SUITE F
COLUMBUS WI
53925-2401
US

V. Phone/Fax

Practice location:
  • Phone: 920-623-9970
  • Fax: 920-623-9970
Mailing address:
  • Phone: 920-623-9970
  • Fax: 920-623-9970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number7089
License Number StateMT

VIII. Authorized Official

Name: DR. MICHAEL ERVIN KUGLITSCH
Title or Position: OWNER
Credential: MD
Phone: 920-623-9970