Healthcare Provider Details

I. General information

NPI: 1164478475
Provider Name (Legal Business Name): MARY M. RAJALA, M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 S MAIN ST
OCONTO FALLS WI
54154-1241
US

IV. Provider business mailing address

225 S EXECUTIVE DR
BROOKFIELD WI
53005-4257
US

V. Phone/Fax

Practice location:
  • Phone: 920-846-3444
  • Fax:
Mailing address:
  • Phone: 262-787-4026
  • Fax: 262-782-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MARY M RAJALA
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 920-498-4200