Basic Information
| Provider Information | |||||||||
| NPI: | 1730542408 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THEDACARE, INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8003 | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549128003 | ||||||||
| 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: | 9207487000 | ||||||||
| FaxNumber: | 9207487236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9208305950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | WI2257 | 01 | WI | MEDICARE PTAN | OTHER |