Provider Demographics
NPI:1720177371
Name:ASPIRUS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ASPIRUS MEDICAL GROUP, INC.
Other - Org Name:ASPIRUS WESTON CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2988
Mailing Address - Street 1:29980 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1299
Mailing Address - Country:US
Mailing Address - Phone:715-847-2304
Mailing Address - Fax:715-843-1188
Practice Address - Street 1:4005 COMMUNITY CENTER DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-4139
Practice Address - Country:US
Practice Address - Phone:715-241-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASPIRUS MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
WI261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720177371Medicaid
WI52D1020282OtherCLIA
WI52D1020282OtherCLIA
WI=========250OtherBCBS
WI000039315Medicare PIN
WI0212750012Medicare NSC