Basic Information
| Provider Information | |||||||||
| NPI: | 1407868334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOX VALLEY HEMATOLOGY & ONCOLOGY, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3232 N BALLARD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549118804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207499668 | ||||||||
| FaxNumber: | 9207345307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3925 N GATEWAY DR | ||||||||
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| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549137863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207491171 | ||||||||
| FaxNumber: | 9207491172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | GOGGINS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9207491171 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 293D00000X | WI | N | Laboratories | Physiological Laboratory | 332900000X | WI | N | Suppliers | Non-Pharmacy Dispensing Site | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RH0003X | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 32802700 | 05 | WI | MEDICAID |