Provider Demographics
NPI:1093881609
Name:OPHTHALMIC SURGERY OF WI LTD
Entity Type:Organization
Organization Name:OPHTHALMIC SURGERY OF WI LTD
Other - Org Name:OPHTHALMIC SURGERY OF WISCONSIN LTD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:P
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-236-4160
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54957-0308
Mailing Address - Country:US
Mailing Address - Phone:920-236-4162
Mailing Address - Fax:920-236-4166
Practice Address - Street 1:509 S WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7949
Practice Address - Country:US
Practice Address - Phone:920-236-4160
Practice Address - Fax:920-236-4166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICS8378OtherRETIRED RAILROAD MEDICARE
WI32704500Medicaid
WICS8378OtherRETIRED RAILROAD MEDICARE
WI000071505Medicare ID - Type Unspecified
WI000026053Medicare PIN