NPIMap

Organization Active NPI

Eye Clinic of Wisconsin, S.C.

  • Ophthalmology Physician
  • Antigo, WI
National Provider Identifier
1740264266
Registry record updated Jan 21, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
Legal business name
EYE CLINIC OF WISCONSIN, S.C.
Practice address
109 State Hwy 64
Antigo, WI 54409
Phone
(715) 623-6662
Fax
(715) 623-2400
NPI assigned
Nov 30, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 21, 2025

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

Authorized official

Name
Kimberly Goddard
Title
Coo
Phone
(715) 261-8557

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ophthalmology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207W00000X WI Primary

Addresses

Primary practice location

109 State Hwy 64
Antigo, WI 54409

Mailing address

800 N First St
Wausau, WI 54403-4754
Phone (715) 261-8500

Other identifiers 1

IdentifierTypeStateIssuer
32667800MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040806000745 WI Part B Supplier - Clinic/Group Practice 9436121829 Receives reassigned benefits from 22 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rhinelander, WI; Wisconsin Rapids, WI; Wausau, WI; Stevens Point, WI; Merrill, WI; Medford, WI; Marshfield, WI; Antigo, WI
O20100930018805 WI DME Supplier - Physician - Ophthalmology 9436121829 Practice locations: Antigo, WI

National Provider Directory

National Provider Directory
Tax ID family
Eye Clinic of Wisconsin SC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

109 E State Highway 64
Antigo, WI 54409
Phone (715) 623-6662

Other NPIs on the same Medicare enrollment 7

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Practitioners 22

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

View all 22

NPI Registry JSON

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

{
    "created_epoch": "1133308800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1737417600000",
    "number": "1740264266",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "800 N FIRST ST",
            "city": "WAUSAU",
            "state": "WI",
            "postal_code": "544034754",
            "telephone_number": "715-261-8500",
            "fax_number": "715-261-8665"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "109 STATE HWY 64",
            "city": "ANTIGO",
            "state": "WI",
            "postal_code": "54409",
            "telephone_number": "715-623-6662",
            "fax_number": "715-623-2400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EYE CLINIC OF WISCONSIN, S.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-30",
        "last_updated": "2025-01-21",
        "certification_date": "2025-01-21",
        "status": "A",
        "authorized_official_last_name": "GODDARD",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "715-261-8557"
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology",
            "state": "WI",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32667800",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Antigo, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 21, 2025; 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.