Provider Demographics
NPI:1376656959
Name:THEDACARE, INCORPORATED
Entity Type:Organization
Organization Name:THEDACARE, INCORPORATED
Other - Org Name:THEDACARE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
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:920-454-4229
Mailing Address - Fax:920-993-5001
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-830-5900
Practice Address - Fax:920-830-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32883500Medicaid
WIWI2721OtherMEDICARE PTAN
WIWI2721OtherMEDICARE PTAN
WI71129Medicare PIN
=========094OtherBCBS BILLING NUMBER
WICS5215Medicare PIN
WI000045003Medicare PIN
WIWI2721OtherMEDICARE PTAN
WIW12257Medicare PIN