Basic Information
| Provider Information | |||||||||
| NPI: | 1194048256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. NICHOLAS HOSPITAL-SISTERS OF THE THIRD ORDER OF ST. FRANCIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST NICHOLAS HOSPITAL OUTPATIENT LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SUPERIOR AVE | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530811948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204598300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 SUPERIOR AVE | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530811948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204598300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2010 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SELLE | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9204594798 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. NICHOLAS HOSPITAL-SISTERS OF THE THIRD ORDER OF ST. FRANCIS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.