Healthcare Provider Details

I. General information

NPI: 1699719310
Provider Name (Legal Business Name): DICKINSON COUNTY HEALTHCARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 KENNY DR
WAUSAUKEE WI
54177-9627
US

IV. Provider business mailing address

1000 N OAK AVE ATTN: PROVIDER ENROLLMENT SERVICES - SHP FL 2
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 877-770-6983
  • Fax: 715-856-6985
Mailing address:
  • Phone: 715-389-0660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: CHARLES NELSON
Title or Position: CEO
Credential:
Phone: 906-776-5500