=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235253691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELOIT CLINIIC, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307 OGDEN AVE
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53525-9007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-364-1348
-----------------------------------------------------
Fax | 608-364-2338
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1905 E HUEBBE PKWY
-----------------------------------------------------
City | BELOIT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53511-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-364-1348
-----------------------------------------------------
Fax | 608-364-2338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT ADMINISTRATOR
-----------------------------------------------------
Name | RUTH GRAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-364-1348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------