Provider Demographics
NPI:1710333893
Name:THEDACARE MEDICAL CENTER - WAUPACA, INC.
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - WAUPACA, INC.
Other - Org Name:RIVERSIDE MEDICAL CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-830-5885
Mailing Address - Street 1:PO BOX 2759
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-2759
Mailing Address - Country:US
Mailing Address - Phone:715-258-1000
Mailing Address - Fax:
Practice Address - Street 1:N2610 WI 22
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981
Practice Address - Country:US
Practice Address - Phone:715-258-1021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THEDACARE MEDICAL CENTER - WAUPACA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-09
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3031282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI521334OtherMEDICARE PTAN