MEDICARE: BELOIT CLINIC, 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	207Q00000X	Family Medicine Physician		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	:	1346364718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELOIT CLINIC, S.C.

Provider Business Mailing Address
First Line	:	1905 E HUEBBE PKWY
Second Line	:
City	:	BELOIT
State	:	WI
Zip	:	53511-1842
Country	:	US
Telephone Number	:	608-364-1348
Fax Number	:	608-364-2338

Provider Business Practice Location Address
First Line	:	1701 BLACKHAWK BLVD
Second Line	:
City	:	SOUTH BELOIT
State	:	IL
Zip	:	61080-2407
Country	:	US
Telephone Number	:	608-364-1348
Fax Number	:	608-364-2338

Authorized Official
Title or Position	:	ASSISTANT ADMINISTRATOR
Name	:	RUTH GRAY
Credential	:
Telephone Number	:	608-364-1348

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	08/22/2020

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