Provider Demographics
NPI:1952354698
Name:NORTHERN WATERS OPHTHALMOLOGY SC
Entity Type:Organization
Organization Name:NORTHERN WATERS OPHTHALMOLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:SNEED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-682-0363
Mailing Address - Street 1:2111 BEASER AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3608
Mailing Address - Country:US
Mailing Address - Phone:715-682-0363
Mailing Address - Fax:715-682-9638
Practice Address - Street 1:2111 BEASER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3608
Practice Address - Country:US
Practice Address - Phone:715-682-0363
Practice Address - Fax:715-682-9638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32838900Medicaid
5705960001Medicare NSC
000012004Medicare PIN
WI32838900Medicaid