Basic Information
| Provider Information | |||||||||
| NPI: | 1023065356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MEDICAL CENTER OF OSHKOSH, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ASCENSION NE WISCONSIN MERCY HOSPITAL, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 S OAKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207201464 | ||||||||
| FaxNumber: | 9207201728 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S OAKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207201464 | ||||||||
| FaxNumber: | 9207201728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 10/23/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSEN | ||||||||
| AuthorizedOfficialFirstName: | TRAVIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4144653721 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 186 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00228 | 01 | MEDICARE PART B | OTHER | 00228 | 01 | MMC D/B/A THE KENNEDY CENTER | OTHER | 32771900 | 05 | WI | MEDICAID | 11010100 | 05 | WI | MEDICAID | 11010121 | 05 | WI | MEDICAID | 11010126 | 05 | WI | MEDICAID | 41222300 | 05 | WI | MEDICAID | 32944600 | 05 | WI | MEDICAID |