1619025889 NPI number — CITY OF FOND DU LAC

Table of content: (NPI 1619025889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619025889 NPI number — CITY OF FOND DU LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF FOND DU LAC
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:
Provider Other Organization Name Type Code:
6
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:
1619025889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 S MACY ST
Provider Second Line Business Mailing Address:
PO BOX 150
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54935-4241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-322-3454
Provider Business Mailing Address Fax Number:
920-322-3402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 S MAIN 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:
54935-5738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-322-3800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BAUS
Authorized Official First Name:
EILEEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SENIOR ACCOUNTANT
Authorized Official Telephone Number:
920-322-3454

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  6000344 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 41323900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 590094069 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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