Provider Demographics
NPI:1215942867
Name:RACHAEL WEIDERHOLD D.O. INC
Entity type:Organization
Organization Name:RACHAEL WEIDERHOLD D.O. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:414-545-5542
Mailing Address - Street 1:9004 W LINCOLN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2452
Mailing Address - Country:US
Mailing Address - Phone:414-545-5542
Mailing Address - Fax:414-545-5548
Practice Address - Street 1:9004 W LINCOLN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2452
Practice Address - Country:US
Practice Address - Phone:414-545-5542
Practice Address - Fax:414-545-5548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30057700Medicaid
WI0000 01172Medicare ID - Type Unspecified