Provider Demographics
NPI:1376587337
Name:ST. MARYS DEAN VENTURES INC.
Entity Type:Organization
Organization Name:ST. MARYS DEAN VENTURES INC.
Other - Org Name:AYAZ SAMADANI MD CAMBRIA
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:608-260-3586
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA
Mailing Address - State:WI
Mailing Address - Zip Code:53923-0024
Mailing Address - Country:US
Mailing Address - Phone:920-348-5114
Mailing Address - Fax:920-348-5113
Practice Address - Street 1:306 E EDGEWATER ST
Practice Address - Street 2:
Practice Address - City:CAMBRIA
Practice Address - State:WI
Practice Address - Zip Code:53923-8809
Practice Address - Country:US
Practice Address - Phone:920-348-5114
Practice Address - Fax:920-348-5113
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARYS DEAN VENTURES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
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
WIM43OtherDEAN HEALTH INSURANCE
WI137082517OtherOFFICE OF WORKERS COMP
WI32824600Medicaid
WI=========059OtherTRICARE
WI=========059OtherTRICARE
WI=========POtherWPS