Basic Information
| Provider Information | |||||||||
| NPI: | 1447319702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ECLAVEA | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 117 | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549120117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207395642 | ||||||||
| FaxNumber: | 9208860430 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 N MEADE ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549113454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207395642 | ||||||||
| FaxNumber: | 9208860430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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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 | 2085R0202X | 50367 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 50367 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 34785300 | 05 | WI | MEDICAID |