Provider Demographics
NPI:1700907045
Name:WISCONSIN RETINA, S.C.
Entity Type:Organization
Organization Name:WISCONSIN RETINA, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-777-0110
Mailing Address - Street 1:2600 N MAYFAIR RD STE 350
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1372
Mailing Address - Country:US
Mailing Address - Phone:414-777-0110
Mailing Address - Fax:414-777-0330
Practice Address - Street 1:2600 N MAYFAIR RD STE 350
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1372
Practice Address - Country:US
Practice Address - Phone:414-777-0110
Practice Address - Fax:414-777-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39513261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32394500Medicaid
WI32394500Medicaid
WI01604Medicare ID - Type Unspecified