Provider Demographics
NPI:1164467130
Name:ST. MARYS DEAN VENTURES INC.
Entity Type:Organization
Organization Name:ST. MARYS DEAN VENTURES INC.
Other - Org Name:WAUPUN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRINNALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-260-3586
Mailing Address - Street 1:612 W BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1702
Mailing Address - Country:US
Mailing Address - Phone:920-324-5043
Mailing Address - Fax:920-324-6768
Practice Address - Street 1:612 W BROWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1702
Practice Address - Country:US
Practice Address - Phone:920-324-5043
Practice Address - Fax:920-324-6768
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARYS DEAN VENTURES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI137082535OtherOFFICE OF WORKERS COMP
WIN65OtherDEAN HEALTH INSURANCE
WI32824600Medicaid
WI=========0L0OtherBLUE CROSS BLUE SHIELD
WI137082535OtherOFFICE OF WORKERS COMP
WI32824600Medicaid
WICD8126Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WIN65OtherDEAN HEALTH INSURANCE
WI000054375Medicare PIN