Provider Demographics
NPI:1124176268
Name:MAEDKE, RICHARD CHARLES (DC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHARLES
Last Name:MAEDKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4228 N WOODBURN ST
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1503
Mailing Address - Country:US
Mailing Address - Phone:414-964-1685
Mailing Address - Fax:
Practice Address - Street 1:1410 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1901
Practice Address - Country:US
Practice Address - Phone:414-906-8081
Practice Address - Fax:414-906-8093
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2789-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38866900Medicaid
WI38866900Medicare UPIN