Basic Information
| Provider Information | |||||||||
| NPI: | 1144466608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOND DU LAC PSYCHIATRY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 S MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549356102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209239054 | ||||||||
| FaxNumber: | 9203229193 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 S MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549356102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209239054 | ||||||||
| FaxNumber: | 9203229193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2009 | ||||||||
| LastUpdateDate: | 01/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | JUNIG | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9209239054 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 32668-020 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 31769900 | 05 | WI | MEDICAID |