Provider Demographics
| NPI: | 1891751186 |
|---|---|
| Name: | DICKINSON COUNTY HEALTHCARE SYSTEM |
| Entity Type: | Organization |
| Organization Name: | DICKINSON COUNTY HEALTHCARE SYSTEM |
| Other - Org Name: | MARSHFIELD MEDICAL CENTER - DICKINSON PROFESSIONAL SERVICES |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | COO, AO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | KATHLEEN |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | BRESSLER |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 715-975-6018 |
| Mailing Address - Street 1: | 1000 N OAK AVE |
| Mailing Address - Street 2: | ATTN: PROVIDER ENROLLMENT COORDINATOR SHP FL 2 |
| Mailing Address - City: | MARSHFIELD |
| Mailing Address - State: | WI |
| Mailing Address - Zip Code: | 54449-5703 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 715-389-0660 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 1721 S STEPHENSON AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | IRON MOUNTAIN |
| Practice Address - State: | MI |
| Practice Address - Zip Code: | 49801-3637 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 906-774-1313 |
| Practice Address - Fax: | 906-776-5639 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | MARSHFIELD CLINIC HEALTH SYSTEM INC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-04-25 |
| Last Update Date: | 2023-10-26 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 204D00000X, 207PE0004X, 207Q00000X, 207R00000X, 207RN0300X, 207V00000X, 207X00000X, 207Y00000X, 207ZC0500X, 208000000X, 2084N0400X, 2085R0202X, 363A00000X, 363LF0000X | ||
| MI | 390200000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207PE0004X | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | Group - Multi-Specialty |
| No | 204D00000X | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 207ZC0500X | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | Group - Multi-Specialty |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | C15304 | Other | RAILROAD MEDICARE GROUP |
| WI | 21250500 | Medicaid | |
| WI | 43061200 | Medicaid | |
| MI | CF9850 | Other | RAILROAD MEDICARE GROUP |
| WI | 21257100 | Medicaid | |
| MI | CB9760 | Other | RAILROAD MEDICARE GROUP |
| MI | CC2021 | Other | RAILROAD MEDICARE GROUP |
| WI | 21256300 | Medicaid | |
| WI | 21312000 | Medicaid | |
| WI | 32827000 | Medicaid | |
| MI | 700B260020 | Other | MI BLUE CROSS PHYS GRP |
| WI | CG4003 | Other | RAILROAD MEDICARE GROUP |
| WI | 43058200 | Medicaid | |
| MI | CA7347 | Other | RAILROAD MEDICARE GROUP |
| WI | 21256900 | Medicaid | |
| WI | 21256900 | Medicaid | |
| WI | 21250500 | Medicaid | |
| WI | 21010 | Medicare PIN | |
| MI | 0N87160 | Medicare PIN | |
| WI | WI1196 | Medicare PIN |
