Basic Information
| Provider Information | |||||||||
| NPI: | 1427009992 | ||||||||
| 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 RENAL DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SUPERIOR AVE | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530811948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204598300 | ||||||||
| FaxNumber: | 9204528336 | ||||||||
| Practice Location | |||||||||
| Address1: | 2925 SAEMANN AVE | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530811948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204594790 | ||||||||
| FaxNumber: | 9207830766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | SELLE | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9204594798 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 11009800 | 05 | WI | MEDICAID |