Provider Demographics
NPI:1003583238
Name:PHELPS, ERIC GERALD
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:GERALD
Last Name:PHELPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:CORNELL
Mailing Address - State:WI
Mailing Address - Zip Code:54732-8106
Mailing Address - Country:US
Mailing Address - Phone:715-202-3586
Mailing Address - Fax:
Practice Address - Street 1:104 N 11TH ST
Practice Address - Street 2:
Practice Address - City:CORNELL
Practice Address - State:WI
Practice Address - Zip Code:54732-8106
Practice Address - Country:US
Practice Address - Phone:715-202-3586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100178091Medicaid