Provider Demographics
NPI:1215987755
Name:KOELLER, ARLYN A (MD)
Entity type:Individual
Prefix:DR
First Name:ARLYN
Middle Name:A
Last Name:KOELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7665 US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54847-4690
Mailing Address - Country:US
Mailing Address - Phone:715-372-5001
Mailing Address - Fax:715-372-5067
Practice Address - Street 1:7665 US HIGHWAY 2
Practice Address - Street 2:THE LAKES COMMUNITY HEALTH CENTER
Practice Address - City:IRON RIVER
Practice Address - State:WI
Practice Address - Zip Code:54847-4690
Practice Address - Country:US
Practice Address - Phone:715-372-5001
Practice Address - Fax:715-372-5067
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30972300Medicaid
WI000304005Medicare ID - Type Unspecified
WI30972300Medicaid