Provider Demographics
NPI:1073610242
Name:E JOHN ELDRIDGE MD SC
Entity Type:Organization
Organization Name:E JOHN ELDRIDGE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ELDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-652-9500
Mailing Address - Street 1:1400 75TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143
Mailing Address - Country:US
Mailing Address - Phone:262-652-9500
Mailing Address - Fax:262-652-0760
Practice Address - Street 1:1400 75TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143
Practice Address - Country:US
Practice Address - Phone:262-652-9500
Practice Address - Fax:262-652-0760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25921207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31384000Medicaid
WI31384000Medicaid