Basic Information
Provider Information
NPI: 1821151366
EntityType: 2
ReplacementNPI:  
OrganizationName: LANGLADE HOSPITAL - HOTEL DIEU OF ST JOSEPH OF ANTIGO WISCONSIN
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: ASPIRUS ANTIGO CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 29980 NETWORK PL
Address2:  
City: CHICAGO
State: IL
PostalCode: 606731299
CountryCode: US
TelephoneNumber: 7158472304
FaxNumber:  
Practice Location
Address1: 110 E 5TH AVE
Address2:  
City: ANTIGO
State: WI
PostalCode: 544092710
CountryCode: US
TelephoneNumber: 7156232351
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/18/2006
LastUpdateDate: 11/10/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: PECK
AuthorizedOfficialFirstName: LORI
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: VP REVENUE CYCLE
AuthorizedOfficialTelephone: 7158472988
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 11/10/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 
261Q00000X WIN Ambulatory Health Care FacilitiesClinic/Center 
261QM1300X  N Ambulatory Health Care FacilitiesClinic/CenterMulti-Specialty
261QR1300X WIY Ambulatory Health Care FacilitiesClinic/CenterRural Health

No ID Information.


Home