Provider Demographics
NPI:1033140397
Name:MANITOWOC SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MANITOWOC SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WILLHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MSOLQ
Authorized Official - Phone:920-683-1250
Mailing Address - Street 1:1720 MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220
Mailing Address - Country:US
Mailing Address - Phone:920-683-1250
Mailing Address - Fax:920-683-1279
Practice Address - Street 1:1720 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-683-1250
Practice Address - Fax:920-683-1279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41915800Medicaid
WI000085167Medicare PIN
WI52C0001072Medicare Oscar/Certification