Basic Information
| Provider Information | |||||||||
| NPI: | 1275943367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THEDACARE MEDICAL CENTER - BERLIN, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHN ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 225 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549231243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203615538 | ||||||||
| FaxNumber: | 9203615499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2014 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9208305885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 11011000 | 05 | WI | MEDICAID |