Healthcare Provider Details

I. General information

NPI: 1417993361
Provider Name (Legal Business Name): FORT HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SHERMAN AVE E
FORT ATKINSON WI
53538-1960
US

IV. Provider business mailing address

PO BOX 249
FORT ATKINSON WI
53538-0249
US

V. Phone/Fax

Practice location:
  • Phone: 920-563-6667
  • Fax: 920-563-0145
Mailing address:
  • Phone: 920-563-6580
  • Fax: 920-568-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHELBY WALLING
Title or Position: PAYER CREDENTIALING SPECIALIST
Credential:
Phone: 920-563-4466