Healthcare Provider Details

I. General information

NPI: 1730126392
Provider Name (Legal Business Name): ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MAIN ST
NEENAH WI
54956-2570
US

IV. Provider business mailing address

101 MAIN ST
NEENAH WI
54956-2570
US

V. Phone/Fax

Practice location:
  • Phone: 920-727-4200
  • Fax:
Mailing address:
  • Phone: 920-727-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: J. BRYAN FISSEL
Title or Position: VP-FINANCE
Credential:
Phone: 414-465-3000