Basic Information
| Provider Information | |||||||||
| NPI: | 1053378331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EWING | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084176000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084178144 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | 47760-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2014182 | 01 | WI | PHYSICIANS PLUS | OTHER | 60427 | 01 | WI | DEAN HEALTH INSURANCE | OTHER | 34628600 | 05 | WI | MEDICAID |