Basic Information
Provider Information | |||||||||
NPI: | 1760413777 | ||||||||
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: | 3 | ||||||||
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: | 225 MEMORIAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | BERLIN | ||||||||
State: | WI | ||||||||
PostalCode: | 549231243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203611313 | ||||||||
FaxNumber: | 9203615579 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 09/06/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMPSON | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9208305885 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CFO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X |   |   | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 11011000 | 05 | WI |   | MEDICAID |