Provider Demographics
NPI:1457370744
Name:PRIMARY CONNECTION HEALTH CARE, INC.
Entity Type:Organization
Organization Name:PRIMARY CONNECTION HEALTH CARE, INC.
Other - Org Name:BRIDGE COMMUNITY HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-848-4884
Mailing Address - Street 1:1810 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3492
Mailing Address - Country:US
Mailing Address - Phone:715-848-4884
Mailing Address - Fax:715-845-5385
Practice Address - Street 1:181 N 2ND STREET
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403
Practice Address - Country:US
Practice Address - Phone:715-848-4884
Practice Address - Fax:715-845-5385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5377-800122300000X, 124Q00000X, 207Q00000X, 208000000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39256400Medicaid
521809Medicare Oscar/Certification
WI521809Medicare Oscar/Certification
WI39245Medicare ID - Type Unspecified
000039245Medicare PIN