Basic Information
| Provider Information | |||||||||
| NPI: | 1437317708 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC | ||||||||
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| OtherOrganizationName: | ASCENSION MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | KIEL | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530421281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207382000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1160 SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | KIEL | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208943322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | MASEK | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP-FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4144653000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 32752000 | 05 | WI | MEDICAID |