Healthcare Provider Details

I. General information

NPI: 1730119561
Provider Name (Legal Business Name): ALAN P. GEGENHEIMER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9697 SAINT CATHERINES DR SUITE 200
PLEASANT PRAIRIE WI
53158-2118
US

IV. Provider business mailing address

6308 8TH AVE ATTN: MEDICAL STAFF OFFICE
KENOSHA WI
53143-5031
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-3590
  • Fax: 262-656-3591
Mailing address:
  • Phone: 262-656-3313
  • Fax: 262-653-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036-099781
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: