Provider Demographics
NPI:1356476543
Name:AGNESIAN HEALTHCARE INC
Entity Type:Organization
Organization Name:AGNESIAN HEALTHCARE INC
Other - Org Name:MERCURY FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:KRUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-907-3907
Mailing Address - Street 1:912 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5530
Mailing Address - Country:US
Mailing Address - Phone:920-929-7490
Mailing Address - Fax:
Practice Address - Street 1:912 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5530
Practice Address - Country:US
Practice Address - Phone:920-929-7490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========101OtherBLUE CROSS BLUE SHIELD