Basic Information
| Provider Information | |||||||||
| NPI: | 1811916281 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT HEALTHCARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | FORT ATKINSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535380249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205685000 | ||||||||
| FaxNumber: | 9205685412 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 SHERMAN AVE E | ||||||||
| Address2: | |||||||||
| City: | FORT ATKINSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535381960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205685000 | ||||||||
| FaxNumber: | 9205685412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9205685000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1908-800 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 43412100 | 05 | WI | MEDICAID | 11011900 | 05 | WI | MEDICAID |