Provider Demographics
NPI:1710206636
Name:THEDACARE MEDICAL CENTER - SHAWANO, INC.
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - SHAWANO, INC.
Other - Org Name:SHAWANO MEDICAL CENTER, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-454-4013
Mailing Address - Street 1:100 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-7072
Mailing Address - Country:US
Mailing Address - Phone:715-526-7328
Mailing Address - Fax:
Practice Address - Street 1:6501 CITY WEST PKWY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3248
Practice Address - Country:US
Practice Address - Phone:715-526-7328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THEDACARE MEDICAL CENTER - SHAWANO, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-18
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site