Provider Demographics
NPI:1740651330
Name:AMS OF WISCONSIN - OSHKOSH
Entity type:Organization
Organization Name:AMS OF WISCONSIN - OSHKOSH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:ERRICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-232-2332
Mailing Address - Street 1:595 S. WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7932
Mailing Address - Country:US
Mailing Address - Phone:920-232-2332
Mailing Address - Fax:920-232-2339
Practice Address - Street 1:595 SOUTH WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904
Practice Address - Country:US
Practice Address - Phone:920-232-2332
Practice Address - Fax:920-232-2339
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMS OF WISCONSIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-08
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3089261QM0801X, 261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)