Basic Information
Provider Information | |||||||||
NPI: | 1760987028 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OCONTO HOSPITAL & MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BELLIN HEALTH PESHTIGO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1866 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543051866 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204457222 | ||||||||
FaxNumber: | 9204457289 | ||||||||
Practice Location | |||||||||
Address1: | 441 FRENCH ST | ||||||||
Address2: |   | ||||||||
City: | PESHTIGO | ||||||||
State: | WI | ||||||||
PostalCode: | 541571203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7155829949 | ||||||||
FaxNumber: | 7155824464 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2018 | ||||||||
LastUpdateDate: | 04/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCGURK | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 9204457260 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.