1417993361 NPI number — FORT HEALTHCARE INC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417993361 NPI number — FORT HEALTHCARE INC

Employer Identification Number (EIN):

Provider Organization Name:

FORT HEALTHCARE INC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

FORT ATKINSON MEMORIAL HEALTH SERVICES

Provider Other Organization Name Type Code:

4

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1417993361

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

10/07/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 249

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

FORT ATKINSON

Provider Business Mailing Address State Name:

WI

Provider Business Mailing Address Postal Code:

53538-0249

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

920-563-4402

Provider Business Mailing Address Fax Number:

920-568-4004

Provider First Line Business Practice Location Address:

611 SHERMAN AVE E

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

FORT ATKINSON

Provider Business Practice Location Address State Name:

WI

Provider Business Practice Location Address Postal Code:

53538-1960

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

920-568-6580

Provider Business Practice Location Address Fax Number:

920-568-4004

Provider Enumeration Date:

06/21/2006

Authorized Official Last Name:

WALLING

Authorized Official First Name:

SHELBY

Authorized Official Middle Name:

Authorized Official Title or Position:

CREDENTIALING SPECIALIST

Authorized Official Telephone Number:

920-563-4466

• Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 21273900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 000000491 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 21273800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21279400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 11011900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21275700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 52D0392916 . This is a "CLIA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
• Identifier: 42237700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 21274700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".