Provider Demographics
NPI:1417450115
Name:FORT HEALTHCARE INC
Entity Type:Organization
Organization Name:FORT HEALTHCARE INC
Other - Org Name:RHC
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-563-4466
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0249
Mailing Address - Country:US
Mailing Address - Phone:920-568-5411
Mailing Address - Fax:920-568-4004
Practice Address - Street 1:500 MCMILLEN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1233
Practice Address - Country:US
Practice Address - Phone:920-563-5571
Practice Address - Fax:920-563-7705
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORT HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-09
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207V00000X, 261QM0801X
WI261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)