Basic Information
Provider Information | |||||||||
NPI: | 1457693079 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | XANTHOPOULOS | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | P. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | BELOIT HEALTH SYSTEM INC | ||||||||
Address2: | 1905 E. HUEBBE PARKWAY | ||||||||
City: | BELOIT | ||||||||
State: | WI | ||||||||
PostalCode: | 535111842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083642293 | ||||||||
FaxNumber: | 6083645452 | ||||||||
Practice Location | |||||||||
Address1: | BELOIT HEALTH SYSTEM UW CANCER CENTER | ||||||||
Address2: | 1670 LEE LANE | ||||||||
City: | BELOIT | ||||||||
State: | WI | ||||||||
PostalCode: | 535113935 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083645253 | ||||||||
FaxNumber: | 6083645252 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2013 | ||||||||
LastUpdateDate: | 03/31/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/31/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 036-146949 | IL | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2085R0001X | 68909-20 | WI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 100075966 | 05 | WI |   | MEDICAID |