Basic Information
Provider Information | |||||||||
NPI: | 1821399965 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARSH COUNTRY HEALTH ALLIANCE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MCHA SOUTH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 199 HOME RD | ||||||||
Address2: |   | ||||||||
City: | JUNEAU | ||||||||
State: | WI | ||||||||
PostalCode: | 530391401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203863400 | ||||||||
FaxNumber: | 9203863800 | ||||||||
Practice Location | |||||||||
Address1: | 199 HOME RD | ||||||||
Address2: |   | ||||||||
City: | JUNEAU | ||||||||
State: | WI | ||||||||
PostalCode: | 530391401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203863400 | ||||||||
FaxNumber: | 9203863800 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2010 | ||||||||
LastUpdateDate: | 11/05/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOOPER | ||||||||
AuthorizedOfficialFirstName: | JANE | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 9203863409 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | NHA RN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X |   | WI | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 314000000X |   | WI | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 20155300 | 05 | WI |   | MEDICAID |