=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942201967
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC W NEWGENT D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2005
-----------------------------------------------------
Last Update Date | 10/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 191 MEMORIAL DR SUITE 300
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54923-1241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-361-5717
-----------------------------------------------------
Fax | 920-361-6361
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3021 VOYAGER DR
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54311-8303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-361-5717
-----------------------------------------------------
Fax | 920-361-6361
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS1201X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 36180
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number | 36180
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------