Provider Demographics
NPI:1588831739
Name:ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
Entity Type:Organization
Organization Name:ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
Other - Org Name:ASCENSION MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP-FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:J. BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3000
Mailing Address - Street 1:618 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-1568
Mailing Address - Country:US
Mailing Address - Phone:920-738-2000
Mailing Address - Fax:
Practice Address - Street 1:618 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CHILTON
Practice Address - State:WI
Practice Address - Zip Code:53014
Practice Address - Country:US
Practice Address - Phone:920-849-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32752000Medicaid
WI10010Medicare PIN