Basic Information
| Provider Information | |||||||||
| NPI: | 1104858836 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EENIGENBURG | ||||||||
| FirstName: | ROYLE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 COUNTY ROAD DF | ||||||||
| Address2: | FL 3 | ||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530399512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203864094 | ||||||||
| FaxNumber: | 9203863812 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 COUNTY ROAD DF | ||||||||
| Address2: | FL 3 | ||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530399512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203864094 | ||||||||
| FaxNumber: | 9203863812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 02/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 34504 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 31968600 | 05 | WI | MEDICAID |