MEDICARE: WESTERN WISCONSIN EAR, NOSE & THROAT CENTER, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	27186	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174535751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN WISCONSIN EAR, NOSE & THROAT CENTER, S.C.

Provider Business Mailing Address
First Line	:	2119 HEIGHTS DR
Second Line	:
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-6130
Country	:	US
Telephone Number	:	715-831-0289
Fax Number	:	715-831-4722

Provider Business Practice Location Address
First Line	:	2119 HEIGHTS DR
Second Line	:
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-6130
Country	:	US
Telephone Number	:	715-831-0289
Fax Number	:	715-831-4722

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD T CRANE
Credential	:	MD
Telephone Number	:	715-831-0289

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	01/13/2010

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