NPIMap

Organization Active NPI

Defatta ENT & Facial Plastic Surgery SC

  • Specialist
  • Altoona, WI
National Provider Identifier
1346664059
Registry record updated May 5, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
55984-20 Issued in WI
Legal business name
DEFATTA ENT & FACIAL PLASTIC SURGERY SC
Practice address
1490 Rivers Edge Trail
Altoona, WI 54720-1495
Phone
(715) 828-2368
Fax
(715) 726-2087
NPI assigned
Feb 17, 2014
Last updated
May 5, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 5, 2014

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

Authorized official

Name
Dr. Robert Joseph Defatta, MD, PH D, FACSNPI 1578697520
Title
Owner
Phone
(715) 828-2368

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X 55984-20 WI Primary
Medical Specialty Clinic/Center 261QM2500X 55984-20 WI

Addresses

Primary practice location

1490 Rivers Edge Trail
Altoona, WI 54720-1495

Mailing address

1490 Rivers Edge Trail
Altoona, WI 54720-1495
Phone (715) 828-2368

Other identifiers 3

IdentifierTypeStateIssuer
1578697520OtherWINPI
100016459MedicaidWI
1790931707OtherWINPI PROVIDER

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140502000083 WI Part B Supplier - Clinic/Group Practice 6103059936 Receives reassigned benefits from 6 practitioners
Practice locations: Altoona, WI

National Provider Directory

National Provider Directory

Locations

1024 N Main St
Rice Lake, WI 54868
Phone (715) 234-7776

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1392595200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1399248000000",
    "number": "1346664059",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1490 RIVERS EDGE TRAIL",
            "city": "ALTOONA",
            "state": "WI",
            "postal_code": "547201495",
            "telephone_number": "715-828-2368",
            "fax_number": "715-726-2087"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1490 RIVERS EDGE TRAIL",
            "city": "ALTOONA",
            "state": "WI",
            "postal_code": "547201495",
            "telephone_number": "715-828-2368",
            "fax_number": "715-726-2087"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEFATTA ENT & FACIAL PLASTIC SURGERY SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-02-17",
        "last_updated": "2014-05-05",
        "status": "A",
        "authorized_official_last_name": "DEFATTA",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "JOSEPH",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "715-828-2368",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD, PH D, FACS"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "WI",
            "license": "55984-20",
            "primary": true
        },
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": "WI",
            "license": "55984-20",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1578697520",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100016459",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI PROVIDER",
            "identifier": "1790931707",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Altoona, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 5, 2014; 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.