1790780708 NPI number — DR. ERIC G EBERTS M.D.

Table of content: DR. ERIC G EBERTS M.D. (NPI 1790780708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790780708 NPI number — DR. ERIC G EBERTS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EBERTS
Provider First Name:
ERIC
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1790780708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3232 N BALLARD RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54911-8804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-729-7105
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 THEDA CLARK MEDICAL PLZ
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
NEENAH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54956-2790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-729-7105
Provider Business Practice Location Address Fax Number:
920-720-2150
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  41754 , 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: 32389700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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