Provider Demographics
NPI:1912078718
Name:EAU CLAIRE GI ASSOCIATES S.C.
Entity Type:Organization
Organization Name:EAU CLAIRE GI ASSOCIATES S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGELTANZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-552-7303
Mailing Address - Street 1:4109 OAKWOOD HILLS PARKWAY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-8888
Mailing Address - Country:US
Mailing Address - Phone:715-552-7303
Mailing Address - Fax:715-552-7355
Practice Address - Street 1:4109 OAKWOOD HILLS PARKWAY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-8888
Practice Address - Country:US
Practice Address - Phone:715-552-7303
Practice Address - Fax:715-552-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37801-020174400000X
207RG0100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICH7600OtherRAILROAD MEDICARE
WI=========OtherTAX ID NUMBER
WICH7600OtherRAILROAD MEDICARE