Provider Demographics
NPI:1730126392
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 1:101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2570
Mailing Address - Country:US
Mailing Address - Phone:920-727-4200
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2570
Practice Address - Country:US
Practice Address - Phone:920-727-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42244300Medicaid
WI32752000Medicaid
WI32752000Medicaid
WI43053800Medicaid
WICC9907Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WI71018Medicare PIN
WI42244300Medicaid
WI523825Medicare ID - Type UnspecifiedRURAL HEALTH CLINTONVILLE
WI43053800Medicaid
WI41683700Medicaid
WI45300Medicare PIN
WI41683700Medicaid
WI43053800Medicaid
WI45300Medicare PIN