Basic Information
Provider Information
NPI: 1326493602
EntityType: 2
ReplacementNPI:  
OrganizationName: THEDACARE MEDICAL CENTER - BERLIN, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: COMMUNITY HEALTH NETWORK, INC. AND BERLIN MEMORIAL HOSPITAL
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: 1080 W FOND DU LAC ST
Address2:  
City: RIPON
State: WI
PostalCode: 549719286
CountryCode: US
TelephoneNumber: 9203611313
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/25/2016
LastUpdateDate: 09/06/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: THOMPSON
AuthorizedOfficialFirstName: MARK
AuthorizedOfficialMiddleName: S
AuthorizedOfficialTitleorPosition: CHIEF FINANCIAL OFFICER
AuthorizedOfficialTelephone: 9208305885
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: THEDACARE MEDICAL CENTER - BERLIN, INC.
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
282NC0060X1060WIY HospitalsGeneral Acute Care HospitalCritical Access

ID Information
IDTypeStateIssuerDescription
52720601WIMEDICARE PTANOTHER


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