Healthcare Provider Details

I. General information

NPI: 1720248958
Provider Name (Legal Business Name): PETER MANDELERT IHLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9891 DEWITZ RD
FALL CREEK WI
54742-9384
US

IV. Provider business mailing address

9891 DEWITZ RD
FALL CREEK WI
54742-9384
US

V. Phone/Fax

Practice location:
  • Phone: 715-877-1514
  • Fax: 715-877-3615
Mailing address:
  • Phone: 715-877-1514
  • Fax: 715-877-3615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16442-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: