Provider Demographics
NPI:1326493602
Name:THEDACARE MEDICAL CENTER - BERLIN, INC.
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - BERLIN, INC.
Other - Org Name:COMMUNITY HEALTH NETWORK, INC. AND BERLIN MEMORIAL HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-454-4013
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:1080 W FOND DU LAC ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-9286
Practice Address - Country:US
Practice Address - Phone:920-361-1313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THEDACARE MEDICAL CENTER - BERLIN, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-25
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1060282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI527206OtherMEDICARE PTAN