1346344678 NPI number — SODERBERG EYE CARE CENTER

Table of content: (NPI 1346344678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346344678 NPI number — SODERBERG EYE CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SODERBERG EYE CARE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENNIS R. SODERBERG O.D.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346344678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
228 PAPERJACK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW RICHMOND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54017-2430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-246-4441
Provider Business Mailing Address Fax Number:
715-246-3250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
228 PAPERJACK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW RICHMOND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54017-2430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-246-4441
Provider Business Practice Location Address Fax Number:
715-246-3250
Provider Enumeration Date:
09/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SODERBERG
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
RAYMOND
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
715-246-4441

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1396 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22-14005 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 371170106044 . This is a "BCBS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38501900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 48421 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".