Basic Information
| Provider Information | |||||||||
| NPI: | 1659452878 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASPIRUS CLINICS, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8004 | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544028004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472304 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1881 COUNTY ROAD XX | ||||||||
| Address2: | |||||||||
| City: | MOSINEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544557933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153554040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7158472988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASPIRUS MEDICAL GROUP, INC. | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CC8777 | 01 | WI | MEDICARE RAILROAD | OTHER | 32848900 | 05 | WI | MEDICAID | 1659452878 | 05 | WI | MEDICAID |