Basic Information
| Provider Information | |||||||||
| NPI: | 1891751186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DICKINSON COUNTY HEALTHCARE SYSTEM | ||||||||
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| OtherOrganizationName: | MARSHFIELD MEDICAL CENTER - DICKINSON PROFESSIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT COORDINATOR SHP FL 2 | ||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153890660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1721 S STEPHENSON AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067741313 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 06/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9607765500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARSHFIELD CLINIC HEALTH SYSTEM INC | ||||||||
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| NPICertificationDate: | 06/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207ZC0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 204D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207PE0004X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.