Basic Information
Provider Information | |||||||||
NPI: | 1427085679 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEAN HEALTH SYSTEMS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SSM HEALTH DAVIS DUEHR DEAN EYE CARE - PORTAGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2825 HUNTERS TRL | ||||||||
Address2: | LOWER LEVEL | ||||||||
City: | PORTAGE | ||||||||
State: | WI | ||||||||
PostalCode: | 539013429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087425522 | ||||||||
FaxNumber: | 6087453054 | ||||||||
Practice Location | |||||||||
Address1: | 2825 HUNTERS TRL | ||||||||
Address2: | LOWER LEVEL | ||||||||
City: | PORTAGE | ||||||||
State: | WI | ||||||||
PostalCode: | 539013429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087425522 | ||||||||
FaxNumber: | 6087453054 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2006 | ||||||||
LastUpdateDate: | 08/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRINNELL | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT-FINANCE | ||||||||
AuthorizedOfficialTelephone: | 6082603586 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   | WI | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 1053358846 | 05 | WI |   | MEDICAID |