Provider Demographics
NPI:1043394562
Name:RICHARD P. JENNINGS D.O. S. C.
Entity Type:Organization
Organization Name:RICHARD P. JENNINGS D.O. S. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:920-887-8646
Mailing Address - Street 1:109 WARREN ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3082
Mailing Address - Country:US
Mailing Address - Phone:920-887-8646
Mailing Address - Fax:920-887-8953
Practice Address - Street 1:109 WARREN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-887-8646
Practice Address - Fax:920-887-8953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29143207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30042200Medicaid
000080316Medicare ID - Type Unspecified
B53854Medicare UPIN