Healthcare Provider Details

I. General information

NPI: 1508819178
Provider Name (Legal Business Name): EAR NOSE AND THROAT SPECIALISTS OF WISCONSIN SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 E BELL ST
NEENAH WI
54956-4993
US

IV. Provider business mailing address

119 E BELL ST
NEENAH WI
54956-4993
US

V. Phone/Fax

Practice location:
  • Phone: 920-969-1768
  • Fax: 920-969-1788
Mailing address:
  • Phone: 920-969-1768
  • Fax: 920-969-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT J BECHARD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 920-969-1768