Provider Demographics
NPI:1689734873
Name:CHIPPEWA VALLEY FOOT AND ANKLE CLINIC SC
Entity Type:Organization
Organization Name:CHIPPEWA VALLEY FOOT AND ANKLE CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:F
Authorized Official - Last Name:CAPORUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:715-832-1400
Mailing Address - Street 1:4212 SOUTHTOWN DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-2635
Mailing Address - Country:US
Mailing Address - Phone:715-832-1400
Mailing Address - Fax:715-832-4187
Practice Address - Street 1:4212 SOUTHTOWN DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-2635
Practice Address - Country:US
Practice Address - Phone:715-832-1400
Practice Address - Fax:715-832-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI848-025213ES0103X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIDB9751OtherMEDICARE RAILROAD
WI43266700Medicaid
WIDB9751OtherMEDICARE RAILROAD
WI000012095Medicare ID - Type UnspecifiedMEDICARE
WI000019070Medicare ID - Type UnspecifiedMEDICARE - RICE LAKE
WI5281420001Medicare NSC