Provider Demographics
NPI:1013069624
Name:NORTHREACH HEALTHCARE, LLC
Entity Type:Organization
Organization Name:NORTHREACH HEALTHCARE, LLC
Other - Org Name:CRIVITZ MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:HIPKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-732-2078
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:218 S HWY 141
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-1677
Practice Address - Country:US
Practice Address - Phone:715-854-7477
Practice Address - Fax:715-854-7785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
WI52D0394395291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52D0394395OtherCLINIC CLIA
WI4825080007OtherMEDICARE DME
WI52D0394395OtherCLINIC CLIA
WI000040160Medicare Oscar/Certification