Basic Information
Provider Information | |||||||||
NPI: | 1780751495 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MADENBERG | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | N2950 STATE ROAD 67 | ||||||||
Address2: |   | ||||||||
City: | LAKE GENEVA | ||||||||
State: | WI | ||||||||
PostalCode: | 531472655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622450535 | ||||||||
FaxNumber: | 2622452248 | ||||||||
Practice Location | |||||||||
Address1: | N2950 STATE ROAD 67 | ||||||||
Address2: |   | ||||||||
City: | LAKE GENEVA | ||||||||
State: | WI | ||||||||
PostalCode: | 531472655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622450535 | ||||||||
FaxNumber: | 2622452248 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2006 | ||||||||
LastUpdateDate: | 07/22/2014 | ||||||||
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 | 207P00000X | 23659-21 | WI | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1780751495 | 05 | WI |   | MEDICAID | MADENDAV | 01 | WI | MERCYCARE INSURANCE | OTHER | 30019800 | 05 | WI |   | MEDICAID |