Healthcare Provider Details

I. General information

NPI: 1619955838
Provider Name (Legal Business Name): WAUPUN MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 03/12/2022
Certification Date: 03/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S PIONEER RD
FOND DU LAC WI
54935-3871
US

IV. Provider business mailing address

PO BOX 1283
FOND DU LAC WI
54936-1283
US

V. Phone/Fax

Practice location:
  • Phone: 920-923-2333
  • Fax: 920-926-8885
Mailing address:
  • Phone: 920-926-4472
  • Fax: 920-926-8885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEVEN N LITTLE
Title or Position: SVP & CFO
Credential:
Phone: 920-926-5402