Basic Information
| Provider Information | |||||||||
| NPI: | 1538232541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH CENTER OF MARSHFIELD, INC. | ||||||||
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| OtherOrganizationName: | FAMILY HEALTH CENTER PHARMACY MARSHFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT SERVICES SHP FL2 | ||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153890660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1307 N SAINT JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544491340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153897474 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | NYCZ | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | FHC - CEO | ||||||||
| AuthorizedOfficialTelephone: | 7153879137 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 33247100 | 05 | WI | MEDICAID |