Provider Demographics
NPI:1275943367
Name:THEDACARE MEDICAL CENTER - BERLIN, INC.
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - BERLIN, INC.
Other - Org Name:CHN ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-830-5885
Mailing Address - Street 1:PO BOX 2759
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-2759
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5538
Practice Address - Fax:920-361-5499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11011000Medicaid
WI000000416Medicare PIN