Healthcare Provider Details

I. General information

NPI: 1568438711
Provider Name (Legal Business Name): MARTHA LEIGH ROLLI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 12/12/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6007 WINNEQUAH ROAD
MONONA WI
53716
US

IV. Provider business mailing address

6007 WINNEQUAH ROAD
MONONA WI
53716
US

V. Phone/Fax

Practice location:
  • Phone: 608-265-8130
  • Fax: 608-263-7263
Mailing address:
  • Phone: 608-235-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34559
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: