Provider Demographics
NPI:1003352733
Name:FOX VALLEY HEMATOLOGY & ONCOLOGY S C
Entity Type:Organization
Organization Name:FOX VALLEY HEMATOLOGY & ONCOLOGY S C
Other - Org Name:FOX VALLEY FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-749-1171
Mailing Address - Street 1:3232 N BALLARD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8804
Mailing Address - Country:US
Mailing Address - Phone:920-749-9668
Mailing Address - Fax:920-734-5307
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-702-4802
Practice Address - Fax:920-702-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9433-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167333OtherPK