Provider Demographics
NPI:1801125976
Name:EDDY D CO MD SC
Entity type:Organization
Organization Name:EDDY D CO MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-645-0920
Mailing Address - Street 1:3267 S 16TH ST
Mailing Address - Street 2:STE 105
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4500
Mailing Address - Country:US
Mailing Address - Phone:414-645-0920
Mailing Address - Fax:
Practice Address - Street 1:3267 S 16TH ST
Practice Address - Street 2:STE 105
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4500
Practice Address - Country:US
Practice Address - Phone:414-645-0920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19814207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI061917005OtherRAILROAD MEDICARE
WI30914600Medicaid
WI000073996Medicare PIN