Provider Demographics
NPI:1447243399
Name:THEDACARE MEDICAL CENTER - BERLIN, INC.
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - BERLIN, INC.
Other - Org Name:CHN - HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRYSTOWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-361-5580
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5555
Mailing Address - Fax:920-361-5300
Practice Address - Street 1:402 PRESTON LANE
Practice Address - Street 2:
Practice Address - City:REDGRANITE
Practice Address - State:WI
Practice Address - Zip Code:54970
Practice Address - Country:US
Practice Address - Phone:920-361-5555
Practice Address - Fax:920-361-5300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THEDACARE MEDICAL CENTER - BERLIN, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-25
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235251E00000X
WI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI527206Medicare ID - Type Unspecified
WI41526500Medicaid