Healthcare Provider Details

I. General information

NPI: 1992853808
Provider Name (Legal Business Name): ASCENSION MEDICAL GROUP-FOX VALLEY WISCONSIN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 DEERWOOD AVE
NEENAH WI
54956
US

IV. Provider business mailing address

1570 MIDWAY PL
MENASHA WI
54952-1165
US

V. Phone/Fax

Practice location:
  • Phone: 920-751-9600
  • Fax:
Mailing address:
  • Phone: 920-720-1464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE SANICOLA
Title or Position: ADMINISTRATIVE VP
Credential:
Phone: 414-465-3968