Provider Demographics
NPI:1740317841
Name:ALEXANDER EYE INSTITUTE, SC
Entity type:Organization
Organization Name:ALEXANDER EYE INSTITUTE, SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMIC TECHNICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:COT/ROOB
Authorized Official - Phone:920-830-2020
Mailing Address - Street 1:250 N METRO DRIVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8571
Mailing Address - Country:US
Mailing Address - Phone:920-830-2020
Mailing Address - Fax:920-830-1118
Practice Address - Street 1:250 N METRO DRIVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8571
Practice Address - Country:US
Practice Address - Phone:920-830-2020
Practice Address - Fax:920-830-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30180207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000147935Medicare ID - Type Unspecified
WIF05698Medicare UPIN