Basic Information
| Provider Information | |||||||||
| NPI: | 1841320884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AGNESIAN HEALTHCARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOLL AND ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 CAMELOT DR | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549358049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209078201 | ||||||||
| FaxNumber: | 9209078209 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 CAMELOT DR | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549358049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209078201 | ||||||||
| FaxNumber: | 9209078209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 02/08/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9209265402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 2226 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 391995430017 | 01 | WI | BCBS GROUP NUMBER | OTHER |