Provider Demographics
NPI:1225306418
Name:DICKINSON COUNTY HEALTHCARE SYSTEM
Entity Type:Organization
Organization Name:DICKINSON COUNTY HEALTHCARE SYSTEM
Other - Org Name:MARSHFIELD MEDICAL CENTER - DICKINSON SLEEP MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-776-5500
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT SERVICES - SHP FL 2
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-389-0660
Mailing Address - Fax:
Practice Address - Street 1:1100 S CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-5518
Practice Address - Country:US
Practice Address - Phone:906-776-5480
Practice Address - Fax:906-228-0203
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHFIELD CLINIC HEALTH SYSTEM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-02
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008443207QS1201X
MI43010886062080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep MedicineGroup - Multi-Specialty
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B26002Medicare PIN