Provider Demographics
NPI:1396840062
Name:ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
Entity Type:Organization
Organization Name:ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
Other - Org Name:ASCENSION MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3968
Mailing Address - Street 1:1570 MIDWAY PL
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1165
Mailing Address - Country:US
Mailing Address - Phone:920-720-1464
Mailing Address - Fax:
Practice Address - Street 1:2725 JACKSON ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901
Practice Address - Country:US
Practice Address - Phone:920-223-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0601860022Medicare NSC