Provider Demographics
NPI:1407067945
Name:DODGE COUNTY MEDICAL FACILITIES
Entity Type:Organization
Organization Name:DODGE COUNTY MEDICAL FACILITIES
Other - Org Name:DODGE COUNTY FACILITY PHYSICIAN SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA RN
Authorized Official - Phone:920-386-3409
Mailing Address - Street 1:199 HOME RD
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:WI
Mailing Address - Zip Code:53039-1401
Mailing Address - Country:US
Mailing Address - Phone:920-386-3400
Mailing Address - Fax:920-386-3800
Practice Address - Street 1:199 HOME RD
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:WI
Practice Address - Zip Code:53039-1401
Practice Address - Country:US
Practice Address - Phone:920-386-3400
Practice Address - Fax:920-386-3800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32823200Medicaid
WI000016120Medicare ID - Type UnspecifiedDODGE COUNTY FAC PHYS SRV
WI32823200Medicaid