Basic Information
| Provider Information | |||||||||
| NPI: | 1447296744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANZER | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 E ENTERPRISE AVE | ||||||||
| Address2: | UNIT C | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207395642 | ||||||||
| FaxNumber: | 9209680259 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 E ENTERPRISE AVE | ||||||||
| Address2: | UNIT C | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207395642 | ||||||||
| FaxNumber: | 9209680259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/16/2008 | ||||||||
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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 | 2085R0202X | 27752 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 31582400 | 05 | WI | MEDICAID |