1962789362 NPI number — EAU CLAIRE MEDICAL CLINIC, S.C.

Table of content: DR. NAN SUNG CHU MD (NPI 1023275385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962789362 NPI number — EAU CLAIRE MEDICAL CLINIC, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAU CLAIRE MEDICAL CLINIC, 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:
1962789362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
703 W HAMILTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701-6938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-839-9280
Provider Business Mailing Address Fax Number:
715-839-9348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 W HAMILTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701-6938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-839-9280
Provider Business Practice Location Address Fax Number:
715-839-9348
Provider Enumeration Date:
11/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KIDESS
Authorized Official First Name:
ANTON
Authorized Official Middle Name:
I
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
715-839-9280

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , 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: 36203500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00374505 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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