Provider Demographics
NPI:1073799664
Name:THEDACARE MEDICAL CENTER - WAUPACA, INC.
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - WAUPACA, INC.
Other - Org Name:RIVERSIDE MEDICAL CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-454-4013
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:800 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1943
Practice Address - Country:US
Practice Address - Phone:715-258-1000
Practice Address - Fax:715-258-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2024-01-02
Deactivation Date:2017-05-13
Deactivation Code:
Reactivation Date:2017-10-18
Provider Licenses
StateLicense IDTaxonomies
WI3031282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32942600Medicaid