Basic Information
| Provider Information | |||||||||
| NPI: | 1679558290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARBACH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 E TIMBER DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545012852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153692300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 444 E TIMBER DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153692300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 16162 | NV | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | 2013001919 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200974430A | 05 | KS | MEDICAID | 1679558290 | 05 | NV | MEDICAID | 948-320 | 01 | WI | STATE LICENSE | OTHER | 1679558290 | 05 | MO | MEDICAID |