Provider Demographics
NPI:1073611083
Name:THEDACARE MEDICAL CENTER - NEW LONDON, INC.
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - NEW LONDON, INC.
Other - Org Name:CRNA'S
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-830-5885
Mailing Address - Street 1:1405 MILL ST
Mailing Address - Street 2:PO BOX 307
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2155
Mailing Address - Country:US
Mailing Address - Phone:920-531-2092
Mailing Address - Fax:920-531-2098
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2092
Practice Address - Fax:920-531-2098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI69110Medicare ID - Type UnspecifiedPART B CRNA'S