1598743726 NPI number — AGNESIAN HEALTHCARE, INC

Table of content: (NPI 1598743726)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598743726 NPI number — AGNESIAN HEALTHCARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGNESIAN 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's Other Name Information

Provider Other Organization Name:
SSM HEALTH BEHAVIORAL HEALTH
Provider Other Organization Name Type Code:
3
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 Information

NPI Number:
1598743726
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 E DIVISION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54935-4560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-929-2300
Provider Business Mailing Address Fax Number:
920-926-8885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 E DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOND DU LAC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54935-4560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-929-2300
Provider Business Practice Location Address Fax Number:
920-926-8885
Provider Enumeration Date:
01/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHMITZ
Authorized Official First Name:
BONNIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
920-926-4480

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 547140 . This is a "DEAN CARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 101159 . This is a "VESTICA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11013000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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