=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285617936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE CLINIC OF WISCONSIN, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2005
-----------------------------------------------------
Last Update Date | 02/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 E BROADWAY AVE
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54451-1835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-748-5775
-----------------------------------------------------
Fax | 715-748-0667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 614 1ST ST
-----------------------------------------------------
City | WAUSAU
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54403-4851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-845-8201
-----------------------------------------------------
Fax | 715-848-1722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/OWNER
-----------------------------------------------------
Name | DOUGLAS T. EDWARDS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 715-261-8540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------