Basic Information
| Provider Information | |||||||||
| NPI: | 1700866399 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS STANLEY HOSPITAL & CLINICS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASPIRUS OWEN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29980 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472304 | ||||||||
| FaxNumber: | 7158431188 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | OWEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152292177 | ||||||||
| FaxNumber: | 7152294450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7158472988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 43060900 | 05 | WI | MEDICAID |