Provider Demographics
NPI:1265507537
Name:ASCENSION MEDICAL GROUP-NORTHERN WISCONSIN, INC
Entity Type:Organization
Organization Name:ASCENSION MEDICAL GROUP-NORTHERN WISCONSIN, INC
Other - Org Name:ASCENSION MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP-REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2988
Mailing Address - Street 1:1901 WESTWOOD CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2892
Mailing Address - Country:US
Mailing Address - Phone:715-355-9775
Mailing Address - Fax:
Practice Address - Street 1:1901 WESTWOOD CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2892
Practice Address - Country:US
Practice Address - Phone:715-355-9775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21298400Medicaid
WI50110Medicare PIN