Provider Demographics
NPI:1326324005
Name:ST. MARYS DEAN VENTURES, INC
Entity Type:Organization
Organization Name:ST. MARYS DEAN VENTURES, INC
Other - Org Name:DEAN CLINIC COLUMBUS FAMILY & SPORTS ORTHOPEDIC CENTER
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:GRINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-626-0035
Mailing Address - Street 1:118 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2104
Mailing Address - Country:US
Mailing Address - Phone:920-356-1000
Mailing Address - Fax:920-356-0719
Practice Address - Street 1:1511 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-2401
Practice Address - Country:US
Practice Address - Phone:920-623-3012
Practice Address - Fax:920-356-0719
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARYS DEAN VENTURES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-26
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
WI32824600Medicaid
WI32824600Medicaid