NPIMap

Organization Active NPI

Theda Clark OB Hospitalists SC

  • Obstetrics & Gynecology Physician
  • Neenah, WI
National Provider Identifier
1295510196
Registry record updated Aug 29, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
Legal business name
THEDA CLARK OB HOSPITALISTS SC
Practice address
130 2ND St
Neenah, WI 54956-2883
Phone
(920) 729-7105
Fax
(920) 831-8306
NPI assigned
Aug 29, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 29, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Eric G Eberts, MDNPI 1790780708
Title
President
Phone
(920) 729-7105

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Obstetrics & Gynecology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207V00000X Primary

Addresses

Primary practice location

130 2ND St
Neenah, WI 54956-2883

Mailing address

3232 N Ballard Rd Ste 100
Appleton, WI 54911-8804
Phone (920) 729-7105

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240127000748 WI Part B Supplier - Clinic/Group Practice 9335592187 Receives reassigned benefits from 15 practitioners
Practice locations: Neenah, WI

National Provider Directory

National Provider Directory

Locations

3232 N Ballard Rd
Ste 100
Appleton, WI 54911

Practitioners & affiliated clinicians

Practitioners 58

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 58

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1693267200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1693267200000",
    "number": "1295510196",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3232 N BALLARD RD STE 100",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549118804",
            "telephone_number": "920-729-7105",
            "fax_number": "920-831-8306"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "130 2ND ST",
            "city": "NEENAH",
            "state": "WI",
            "postal_code": "549562883",
            "telephone_number": "920-729-7105",
            "fax_number": "920-831-8306"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THEDA CLARK OB HOSPITALISTS SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-08-29",
        "last_updated": "2023-08-29",
        "certification_date": "2023-08-25",
        "status": "A",
        "authorized_official_last_name": "EBERTS",
        "authorized_official_first_name": "ERIC",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "920-729-7105",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Neenah, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.