Basic Information
| Provider Information | |||||||||
| NPI: | 1730119561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEGENHEIMER | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6308 8TH AVE | ||||||||
| Address2: | ATTN: MEDICAL STAFF OFFICE | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531435031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626563313 | ||||||||
| FaxNumber: | 2626535850 | ||||||||
| Practice Location | |||||||||
| Address1: | 9697 SAINT CATHERINES DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PLEASANT PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531582118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626563590 | ||||||||
| FaxNumber: | 2626563591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
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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 | 207X00000X | 036-099781 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1730119561 | 05 | WI | MEDICAID |