Basic Information
| Provider Information | |||||||||
| NPI: | 1992878730 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLIN MEMORIAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BELLIN HEALTH FAST CARE MANITOWOC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 CALUMET AVE | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542205427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457377 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3415 CALUMET AVE | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542205427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457377 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 05/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | STROOBANTS | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC PROVIDER MAINTENANCE | ||||||||
| AuthorizedOfficialTelephone: | 9204457222 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 21305700 | 05 | WI | MEDICAID |