Basic Information
Provider Information | |||||||||
NPI: | 1588731798 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAETHER | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 N OAK AVE | ||||||||
Address2: |   | ||||||||
City: | MARSHFIELD | ||||||||
State: | WI | ||||||||
PostalCode: | 544495703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153875511 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1700 W STOUT ST | ||||||||
Address2: |   | ||||||||
City: | RICE LAKE | ||||||||
State: | WI | ||||||||
PostalCode: | 548685000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152368100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2006 | ||||||||
LastUpdateDate: | 12/01/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 23200-020 | WI | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 23200-020 | WI | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 23200-020 | WI | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 30551700 | 05 | WI |   | MEDICAID |