Provider Demographics
NPI:1093157349
Name:AFFINITY HEALTH SYSTEM
Entity Type:Organization
Organization Name:AFFINITY HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3721
Mailing Address - Street 1:308 RUGGLES ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4024
Mailing Address - Country:US
Mailing Address - Phone:920-924-9355
Mailing Address - Fax:
Practice Address - Street 1:411 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2753
Practice Address - Country:US
Practice Address - Phone:920-727-4347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5358-33261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care