Basic Information
| Provider Information | |||||||||
| NPI: | 1720299761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS WAUSAU HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ASPIRUS WOUND CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1008 | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544021008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472229 | ||||||||
| FaxNumber: | 7158472286 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 PINE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472837 | ||||||||
| FaxNumber: | 7158472286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCZYGELSKI | ||||||||
| AuthorizedOfficialFirstName: | SIDNEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7158472121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASPIRUS WAUSAU HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 188 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43951200 | 05 | WI | MEDICAID | 387565277001 | 01 | WI | BCBS | OTHER |