Basic Information
| Provider Information | |||||||||
| NPI: | 1497879878 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELOIT CLINIC SC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ROSCOE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1905 HUEBBE PARKWAY | ||||||||
| Address2: | BELOIT CLINIC SC | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642200 | ||||||||
| FaxNumber: | 6083642338 | ||||||||
| Practice Location | |||||||||
| Address1: | 5605 EAST ROCKTON RD | ||||||||
| Address2: | NORTH POINTE | ||||||||
| City: | ROSCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610737601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155254500 | ||||||||
| FaxNumber: | 6083642338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 02/06/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6083642200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BELOIT CLINIC SC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32808500 | 05 | WI | MEDICAID | 32270100 | 05 | WI | MEDICAID | 483240 | 01 | ILLINOIS MEDICARE | OTHER |