Provider Demographics
NPI:1437221744
Name:PLASTIC SURGERY CLINIC OF EAU CLAIRE, LTD, SC
Entity Type:Organization
Organization Name:PLASTIC SURGERY CLINIC OF EAU CLAIRE, LTD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-833-2116
Mailing Address - Street 1:3221 STEIN BLVD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4398
Mailing Address - Country:US
Mailing Address - Phone:715-833-2116
Mailing Address - Fax:715-833-1068
Practice Address - Street 1:3221 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4398
Practice Address - Country:US
Practice Address - Phone:715-833-2116
Practice Address - Fax:715-833-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26172174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20060Medicare ID - Type Unspecified