Basic Information
| Provider Information | |||||||||
| NPI: | 1033291000 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS MEDFORD HOSPITAL & CLINICS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASPIRUS CARE & REHAB - MEDFORD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 135 S GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544511622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157488100 | ||||||||
| FaxNumber: | 7157488199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 06/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7157488159 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASPIRUS MEDFORD HOSPITAL & CLINICS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2572 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20153400 | 05 | WI | MEDICAID |