Provider Demographics
NPI:1174535751
Name:WESTERN WISCONSIN EAR, NOSE & THROAT CENTER, S.C.
Entity type:Organization
Organization Name:WESTERN WISCONSIN EAR, NOSE & THROAT CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-831-0289
Mailing Address - Street 1:2119 HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6130
Mailing Address - Country:US
Mailing Address - Phone:715-831-0289
Mailing Address - Fax:715-831-4722
Practice Address - Street 1:2119 HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6130
Practice Address - Country:US
Practice Address - Phone:715-831-0289
Practice Address - Fax:715-831-4722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27186207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30834500Medicaid
WI20259Medicare ID - Type Unspecified
WI30834500Medicaid