Basic Information
| Provider Information | |||||||||
| NPI: | 1114422359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENINGER | ||||||||
| FirstName: | MAC | ||||||||
| MiddleName: | ROMAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 E CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549118728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207314101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 E CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549118728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207314101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2018 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 9409514 | KS | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081S0010X | 76726 | WI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 208100000X | 76726 | WI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.