Basic Information
| Provider Information | |||||||||
| NPI: | 1144675745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THEDACARE MEDICAL CENTER - NEW LONDON, INC. | ||||||||
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| OtherOrganizationName: | NEW LONDON FAMILY MEDICAL CENTER, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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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: | 370 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CLINTONVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549291632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208305900 | ||||||||
| FaxNumber: | 9208305910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2016 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9208305885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THEDACARE MEDICAL CENTER - NEW LONDON, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 1029 | WI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 521326 | 01 | WI | MEDICARE PTAN | OTHER |