Basic Information
Provider Information
NPI: 1811155195
EntityType: 2
ReplacementNPI:  
OrganizationName: ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: ASCENSION MEDICAL GROUP
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2700 W 9TH AVE STE 220
Address2:  
City: OSHKOSH
State: WI
PostalCode: 549047865
CountryCode: US
TelephoneNumber: 9207382000
FaxNumber:  
Practice Location
Address1: 2700 W 9TH AVE
Address2: SUITE 220
City: OSHKOSH
State: WI
PostalCode: 54904
CountryCode: US
TelephoneNumber: 9207382000
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/23/2008
LastUpdateDate: 08/18/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MASEK
AuthorizedOfficialFirstName: TIMOTHY
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: VP FINANCE
AuthorizedOfficialTelephone: 4144653000
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 08/18/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM1300X  Y Ambulatory Health Care FacilitiesClinic/CenterMulti-Specialty

ID Information
IDTypeStateIssuerDescription
3275200005WI MEDICAID


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