Basic Information
Provider Information | |||||||||
NPI: | 1134193014 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASPIRUS STANLEY HOSPITAL & CLINICS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASPIRUS STANLEY HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 29980 NETWORK PL | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606731299 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7158472304 | ||||||||
FaxNumber: | 7158431188 | ||||||||
Practice Location | |||||||||
Address1: | 1120 PINE ST | ||||||||
Address2: |   | ||||||||
City: | STANLEY | ||||||||
State: | WI | ||||||||
PostalCode: | 547681297 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156445571 | ||||||||
FaxNumber: | 7156446221 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2006 | ||||||||
LastUpdateDate: | 11/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PECK | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 7158472988 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 52D0396895 | 01 |   | CLIA ID NUMBER | OTHER |