Basic Information
| Provider Information | |||||||||
| NPI: | 1013995521 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THEDACARE MEDICAL CENTER - WAUPACA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RIVERSIDE MEDICAL CENTER, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2759 | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549122759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208305900 | ||||||||
| FaxNumber: | 9208305910 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | WAUPACA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549811943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152581000 | ||||||||
| FaxNumber: | 7152581626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9208305885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 1038 | WI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 1019845001 | 01 | WI | AMERICHOICE MEDICAID | OTHER | 11018600 | 05 | WI | MEDICAID | 11018610 | 05 | WI | MEDICAID | 62766600 | 05 | WI | MEDICAID | 42245200 | 05 | WI | MEDICAID | 701137 | 01 | WI | NETWORK HEALTH PLAN | OTHER | 32942600 | 05 | WI | MEDICAID | CC8778 | 01 | WI | RAILROAD MEDICARE # | OTHER |