Provider Demographics
NPI:1770503534
Name:DAVID A EGGERT MD SC
Entity Type:Organization
Organization Name:DAVID A EGGERT MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:EGGERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-731-3111
Mailing Address - Street 1:2105 E ENTERPRISE AVE
Mailing Address - Street 2:STE 112
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-731-3111
Mailing Address - Fax:920-731-7133
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:STE 112
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-731-3111
Practice Address - Fax:920-731-7133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24506174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30729800Medicaid
WI30729800Medicaid