Provider Demographics
NPI:1083676217
Name:AGNESIAN HEALTHCARE INC
Entity Type:Organization
Organization Name:AGNESIAN HEALTHCARE INC
Other - Org Name:SSM HEALTH FOND DU LAC REGIONAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-926-4979
Mailing Address - Street 1:1808 W BELTLINE HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2334
Mailing Address - Country:US
Mailing Address - Phone:608-250-1593
Mailing Address - Fax:
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8335
Practice Address - Country:US
Practice Address - Phone:920-926-8332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0302620023Medicare NSC