Provider Demographics
NPI:1427009992
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:ST. NICHOLAS HOSPITAL RENAL DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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:920-459-4798
Mailing Address - Street 1:3100 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1948
Mailing Address - Country:US
Mailing Address - Phone:920-459-8300
Mailing Address - Fax:920-452-8336
Practice Address - Street 1:2925 SAEMANN AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1948
Practice Address - Country:US
Practice Address - Phone:920-459-4790
Practice Address - Fax:920-783-0766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11009800Medicaid
520044Medicare Oscar/Certification
522323Medicare ID - Type UnspecifiedRENAL DIALYSIS
52T044Medicare Oscar/Certification