1235113655 NPI number — EYE CLINIC OF WISCONSIN, S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235113655 NPI number — EYE CLINIC OF WISCONSIN, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CLINIC OF WISCONSIN, S.C.
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:
Provider Other Organization Name Type Code:
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:
1235113655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 N 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54403-4754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-261-8500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 O'DAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILL
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-536-2535
Provider Business Practice Location Address Fax Number:
715-536-1261
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
715-261-8500

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , 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: 32667800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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