Healthcare Provider Details

I. General information

NPI: 1417450115
Provider Name (Legal Business Name): FORT HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MCMILLEN ST
FORT ATKINSON WI
53538-1233
US

IV. Provider business mailing address

PO BOX 249
FORT ATKINSON WI
53538-0249
US

V. Phone/Fax

Practice location:
  • Phone: 920-563-5571
  • Fax: 920-563-7705
Mailing address:
  • Phone: 920-568-5411
  • Fax: 920-568-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateWI

VIII. Authorized Official

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