Healthcare Provider Details

I. General information

NPI: 1609109362
Provider Name (Legal Business Name): ROBERT C. ROSENTHAL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WEST AVE S
LA CROSSE WI
54601-4783
US

IV. Provider business mailing address

700 WEST AVE S
LA CROSSE WI
54601-4783
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0940
  • Fax:
Mailing address:
  • Phone: 608-785-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number159803-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: