Provider Demographics
NPI:1023079324
Name:ROETHLISBERGER, MARIE L (MD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:ROETHLISBERGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:L
Other - Last Name:HERWEIJER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 140
Mailing Address - Street 2:5212 COUNTY HIGHWAY M
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-0140
Mailing Address - Country:US
Mailing Address - Phone:608-835-3101
Mailing Address - Fax:
Practice Address - Street 1:5212 COUNTY HIGHWAY M
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-0140
Practice Address - Country:US
Practice Address - Phone:608-835-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine