Basic Information
| Provider Information | |||||||||
| NPI: | 1437274115 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELOIT CLINIC, S.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | OCCUPATIONAL HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1905 E HUEBBE PKWY | ||||||||
| Address2: | |||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083641348 | ||||||||
| FaxNumber: | 6083642338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 LEE LN | ||||||||
| Address2: | |||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535113935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083641348 | ||||||||
| FaxNumber: | 6083642338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | RUTH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6083641348 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | 32834 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32808500 | 05 | WI | MEDICAID |