Provider Demographics
NPI:1457497091
Name:MILWAUKEE EAR NOSE THROAT CLINIC LIMITED
Entity Type:Organization
Organization Name:MILWAUKEE EAR NOSE THROAT CLINIC LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-241-8000
Mailing Address - Street 1:10945 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5078
Mailing Address - Country:US
Mailing Address - Phone:262-241-8000
Mailing Address - Fax:262-241-8096
Practice Address - Street 1:10945 N PORT WASHINGTON RD STE 211
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5078
Practice Address - Country:US
Practice Address - Phone:262-241-8000
Practice Address - Fax:262-241-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30326800Medicaid
WIC01734OtherRRB
WI000046040Medicare ID - Type Unspecified