Provider Demographics
NPI:1811936248
Name:EAU CLAIRE SPINE & ORTHOPEDICS, SC
Entity type:Organization
Organization Name:EAU CLAIRE SPINE & ORTHOPEDICS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:SUNIL
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-858-0320
Mailing Address - Street 1:659 W HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6925
Mailing Address - Country:US
Mailing Address - Phone:715-858-0320
Mailing Address - Fax:715-858-0319
Practice Address - Street 1:659 W HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6925
Practice Address - Country:US
Practice Address - Phone:715-858-0320
Practice Address - Fax:715-858-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37931207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI610080600OtherUS DEPT OF LABOR
WI21282000Medicaid
WI610080600OtherUS DEPT OF LABOR
WIDC8904Medicare PIN
WI000020330Medicare PIN