Provider Demographics
NPI:1538142245
Name:EYE CLINIC OF WISCONSIN, S.C.
Entity Type:Organization
Organization Name:EYE CLINIC OF WISCONSIN, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:J
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:COE
Authorized Official - Phone:715-261-8500
Mailing Address - Street 1:800 1ST ST
Mailing Address - Street 2:PO BOX 689
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-4754
Mailing Address - Country:US
Mailing Address - Phone:715-261-8500
Mailing Address - Fax:715-261-8667
Practice Address - Street 1:2 E OCALA ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3907
Practice Address - Country:US
Practice Address - Phone:715-362-2600
Practice Address - Fax:715-362-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32667800Medicaid
WI000039155Medicare PIN
WI0609550003Medicare NSC