Basic Information
| Provider Information | |||||||||
| NPI: | 1124075536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION NE WISCONSIN, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASCENSION NE WISCONSIN SURGERY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1550 MIDWAY PL | ||||||||
| Address2: | |||||||||
| City: | MENASHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549521165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207201464 | ||||||||
| FaxNumber: | 9207201728 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 MIDWAY PL | ||||||||
| Address2: | |||||||||
| City: | MENASHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207201464 | ||||||||
| FaxNumber: | 9207201728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | HANSELMAN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4144653000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASCENSION NE WISCONSIN, INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 282N00000X | 88 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 41908300 | 05 | WI | MEDICAID |