Provider Demographics
NPI:1316969363
Name:FOX CITIES EYE CLINIC, SC
Entity type:Organization
Organization Name:FOX CITIES EYE CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-734-8714
Mailing Address - Street 1:1301 E NORTHLAND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8582
Mailing Address - Country:US
Mailing Address - Phone:920-734-8714
Mailing Address - Fax:
Practice Address - Street 1:1301 E NORTHLAND AVE STE A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8582
Practice Address - Country:US
Practice Address - Phone:920-734-8714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICH2565OtherRAILROAD MEDICARE
WI32890500Medicaid
WICH2565OtherRAILROAD MEDICARE