Provider Demographics
NPI:1235253691
Name:BELOIT CLINIIC, S.C.
Entity Type:Organization
Organization Name:BELOIT CLINIIC, S.C.
Other - Org Name:CLINTON CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-364-1348
Mailing Address - Street 1:1905 E HUEBBE PKWY
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-1348
Mailing Address - Fax:608-364-2338
Practice Address - Street 1:307 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WI
Practice Address - Zip Code:53525-9007
Practice Address - Country:US
Practice Address - Phone:608-364-1348
Practice Address - Fax:608-364-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32808500Medicaid