Provider Demographics
NPI:1063614048
Name:JACK W HUTTER SC
Entity type:Organization
Organization Name:JACK W HUTTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-567-4724
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-0192
Mailing Address - Country:US
Mailing Address - Phone:262-567-4724
Mailing Address - Fax:262-567-5195
Practice Address - Street 1:422 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3749
Practice Address - Country:US
Practice Address - Phone:262-567-4724
Practice Address - Fax:262-567-5195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-02
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI474213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0919940001Medicare NSC
T62282Medicare UPIN
WI84450Medicare UPIN