Basic Information
| Provider Information | |||||||||
| NPI: | 1770706624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOX VALLEY HEMATOLOGY & ONCOLOGY, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3232 N BALLARD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549118804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207499668 | ||||||||
| FaxNumber: | 9207345307 | ||||||||
| Practice Location | |||||||||
| Address1: | N3063 CTY QQ | ||||||||
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| City: | WAUPACA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549819796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156024900 | ||||||||
| FaxNumber: | 9207491172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | GOGGINS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9207491171 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOX VALLEY HEMATOLOGY & ONCOLOGY, S.C. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0886830002 | 01 | WI | DME MAC | OTHER | 32802700 | 05 | WI | MEDICAID |