Basic Information
| Provider Information | |||||||||
| NPI: | 1225306418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DICKINSON COUNTY HEALTHCARE SYSTEM | ||||||||
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| OtherOrganizationName: | MARSHFIELD MEDICAL CENTER - DICKINSON SLEEP MEDICINE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT SERVICES - SHP FL 2 | ||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153890660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 S CARPENTER AVE | ||||||||
| Address2: | |||||||||
| City: | KINGSFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498025518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765480 | ||||||||
| FaxNumber: | 9062280203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2011 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9067765500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARSHFIELD CLINIC HEALTH SYSTEM INC | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080S0012X | 4301088606 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Sleep Medicine | 207QS1201X | 5101008443 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine |
No ID Information.