Basic Information
| Provider Information | |||||||||
| NPI: | 1013132430 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS MEDFORD HOSPITAL & CLINICS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ASPIRUS PHARMACY - MEDFORD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 135 S GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544511622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157488100 | ||||||||
| FaxNumber: | 7157488199 | ||||||||
| Practice Location | |||||||||
| Address1: | 139 S GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157485800 | ||||||||
| FaxNumber: | 7157487599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7157488159 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASPIRUS MEDFORD HOSPITAL & CLINICS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 33252200 | 05 | WI | MEDICAID |