Provider Demographics
NPI:1740263458
Name:EYE CLINIC OF WISCONSIN SC
Entity type:Organization
Organization Name:EYE CLINIC OF WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-261-8557
Mailing Address - Street 1:800 N 1ST ST
Mailing Address - Street 2:
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 1:800 N 1ST ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4754
Practice Address - Country:US
Practice Address - Phone:715-261-8500
Practice Address - Fax:715-261-8667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2025-01-21
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
WI0609550001Medicare NSC