Provider Demographics
NPI:1093982530
Name:ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
Entity Type:Organization
Organization Name:ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
Other - Org Name:ASCENSION MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP-FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:J. BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3000
Mailing Address - Street 1:1420 ALGOMA ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2104
Mailing Address - Country:US
Mailing Address - Phone:920-738-2000
Mailing Address - Fax:
Practice Address - Street 1:1420 ALGOMA ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961
Practice Address - Country:US
Practice Address - Phone:920-982-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32752000Medicaid
WI32752000Medicaid