Basic Information
| Provider Information | |||||||||
| NPI: | 1588600696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GASSNER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3006 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204991428 | ||||||||
| FaxNumber: | 9204995808 | ||||||||
| Practice Location | |||||||||
| Address1: | 1789 SHAWANO AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204991428 | ||||||||
| FaxNumber: | 9204995808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 10/08/2009 | ||||||||
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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 | 28941020 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4723988 | 01 | MI | MICHIGAN MEDICAID | OTHER | 1018745003 | 01 | UNITED HEALTHCARE MEDICAI | OTHER | 4767178 | 01 | MI | MICHIGAN MEDICAID | OTHER | 14404 | 01 | DEAN HEALTH | OTHER | 300020918 | 01 | RAILROAD MEDICARE | OTHER | 31496900 | 05 | WI | MEDICAID | 1018745002 | 01 | UNITED HEALTHCARE MEDICAI | OTHER | 567565 | 01 | DEAN HEALTH | OTHER |