Basic Information
| Provider Information | |||||||||
| NPI: | 1649821760 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THEDACARE MEDICAL CENTER - SHAWANO, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 NEENAH CTR | ||||||||
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| City: | NEENAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549563070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204544229 | ||||||||
| FaxNumber: | 9209935001 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 COUNTY ROAD B | ||||||||
| Address2: | |||||||||
| City: | SHAWANO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541667072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155242161 | ||||||||
| FaxNumber: | 7155248164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2019 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9208305885 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.