=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437427333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOWER CLOCK SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2011
-----------------------------------------------------
Last Update Date | 12/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1077 W MASON ST
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54303-1858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-499-3102
-----------------------------------------------------
Fax | 920-499-9636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1087 W MASON ST
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54303-1859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-499-3102
-----------------------------------------------------
Fax | 920-499-9636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPHTHALMOLOGIST
-----------------------------------------------------
Name | DR. MATTHEW J THOMPSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 920-499-3102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------