Provider Demographics
NPI:1336322502
Name:T.J. PEASE & ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:T.J. PEASE & ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEASE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-469-0606
Mailing Address - Street 1:2324 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-4536
Mailing Address - Country:US
Mailing Address - Phone:920-469-0606
Mailing Address - Fax:
Practice Address - Street 1:2324 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-4536
Practice Address - Country:US
Practice Address - Phone:920-469-0606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1547035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38548600Medicaid
WI38548600Medicaid
WI0531240001Medicare NSC