1063635910 NPI number — FOX VALLEY HEMATOLOGY & ONCOLOGY, S.C.

Table of content: (NPI 1063635910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063635910 NPI number — FOX VALLEY HEMATOLOGY & ONCOLOGY, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOX VALLEY HEMATOLOGY & ONCOLOGY, S.C.
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:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063635910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3232 N BALLARD RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54911-8804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-749-9668
Provider Business Mailing Address Fax Number:
920-734-5307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 THEDA CLARK MEDICAL PLZ
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
NEENAH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54956-2763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-729-5833
Provider Business Practice Location Address Fax Number:
920-729-3170
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOGGINS
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
F
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER/PHYSICIAN
Authorized Official Telephone Number:
920-749-1171

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0886830007 . This is a "DMEPOS - DMEMAC" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 32802700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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