Provider Demographics
NPI:1407202831
Name:ST. NICHOLAS HOSPITAL-SISTERS OF THE THIRD ORDER OF ST. FRANCIS
Entity Type:Organization
Organization Name:ST. NICHOLAS HOSPITAL-SISTERS OF THE THIRD ORDER OF ST. FRANCIS
Other - Org Name:PREVEA KOHLER WOODLAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-496-4700
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:950 WOODLAKE RD
Practice Address - Street 2:
Practice Address - City:KOHLER
Practice Address - State:WI
Practice Address - Zip Code:53044-1348
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. NICHOLAS HOSPITAL-SISTERS OF THE THIRD ORDER OF ST. FRANCIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-04
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X, 208D00000X, 247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty