Provider Demographics
NPI:1497879878
Name:BELOIT CLINIC SC
Entity Type:Organization
Organization Name:BELOIT CLINIC SC
Other - Org Name:ROSCOE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:608-364-2200
Mailing Address - Street 1:1905 HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT CLINIC SC
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-364-2338
Practice Address - Street 1:5605 EAST ROCKTON RD
Practice Address - Street 2:NORTH POINTE
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7601
Practice Address - Country:US
Practice Address - Phone:815-525-4500
Practice Address - Fax:608-364-2338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELOIT CLINIC SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-19
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32808500Medicaid
WI32270100Medicaid
483240OtherILLINOIS MEDICARE