Basic Information
| Provider Information | |||||||||
| NPI: | 1689602807 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DICKINSON COUNTY HEALTHCARE SYSTEM | ||||||||
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| OtherOrganizationName: | (INACTIVE)DICKINSON RENAL DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT SERVICES/WWP | ||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153890660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1711 S STEPHENSON AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765640 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9067765500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARSHFIELD CLINIC HEALTH SYSTEM INC | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.