Provider Demographics
NPI:1124277009
Name:BEAVER DAM ENT LLC
Entity type:Organization
Organization Name:BEAVER DAM ENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:K
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ABRAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:920-887-4041
Mailing Address - Street 1:707 S UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3027
Mailing Address - Country:US
Mailing Address - Phone:920-887-6383
Mailing Address - Fax:
Practice Address - Street 1:707 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3027
Practice Address - Country:US
Practice Address - Phone:920-887-6383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1052001Medicare PIN
WIWI1052Medicare PIN