Provider Demographics
NPI:1801807375
Name:WISCONSIN EATING DISORDER SPECIALISTS SC
Entity type:Organization
Organization Name:WISCONSIN EATING DISORDER SPECIALISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELTZIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-646-4411
Mailing Address - Street 1:3630 N HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4532
Mailing Address - Country:US
Mailing Address - Phone:262-646-1387
Mailing Address - Fax:262-646-7067
Practice Address - Street 1:34700 VALLEY RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4500
Practice Address - Country:US
Practice Address - Phone:262-646-1387
Practice Address - Fax:262-646-7067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21282400Medicaid