Basic Information
Provider Information | |||||||||
NPI: | 1073799664 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THEDACARE MEDICAL CENTER - WAUPACA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RIVERSIDE MEDICAL CENTER, INC. | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 01/14/2008 | ||||||||
LastUpdateDate: | 09/06/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 05/13/2017 | ||||||||
NPIReactivationDate: | 10/18/2017 | ||||||||
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 | 3031 | WI | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 32942600 | 05 | WI |   | MEDICAID |