Basic Information
| Provider Information | |||||||||
| NPI: | 1568494466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARYS DEAN VENTURES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DAVIS DUEHR DEAN REGIONAL EYE CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 TUTTLE ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083562020 | ||||||||
| FaxNumber: | 6083566787 | ||||||||
| Practice Location | |||||||||
| Address1: | 1626 TUTTLE ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083562020 | ||||||||
| FaxNumber: | 6083566787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRINNELL | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 6082603586 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. MARYS DEAN VENTURES INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | WI | N | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery | 261QM1300X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 38715000 | 05 | WI | MEDICAID | 38715900 | 05 | WI | MEDICAID | 38720000 | 05 | WI | MEDICAID | 38723700 | 05 | WI | MEDICAID | 38711700 | 05 | WI | MEDICAID | 38719500 | 05 | WI | MEDICAID | 38710800 | 05 | WI | MEDICAID | 38720600 | 05 | WI | MEDICAID | 38611600 | 05 | WI | MEDICAID | 38714900 | 05 | WI | MEDICAID | 38715600 | 05 | WI | MEDICAID | 21257000 | 05 | WI | MEDICAID | 38718300 | 05 | WI | MEDICAID | 38715400 | 05 | WI | MEDICAID | 38718200 | 05 | WI | MEDICAID |